Which is the most important assessment for the nurse to conduct following the administration of epidural anesthesia to a client who is at 40-weeks gestation?

Maternal blood pressure.

Level of pain sensation.

Station of presenting part.

Variability of fetal heart rate.

Answer and Explanation

The Correct Answer is A

Choice A rationale

Maternal blood pressure is crucial to monitor post-epidural anesthesia, as hypotension is a common side effect. Prompt detection and management of low blood pressure are vital to ensuring maternal and fetal well-being, making this the most important assessment.

Choice B rationale

Monitoring pain sensation helps determine the effectiveness of the epidural and the level of anesthesia. However, it is secondary to monitoring for hypotension, which can have more immediate and severe consequences.

Choice C rationale

The station of the presenting part is important for labor progression assessment but not as critical as monitoring for hypotension, which can significantly impact both the mother and fetus.

Choice D rationale

Fetal heart rate variability is vital, but immediate maternal hypotension management takes precedence, as it directly affects fetal oxygenation. .

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Correct Answer is C

Explanation

Choice A rationale

Reduction of fever is not the primary goal of albumin therapy. Albumin's role in nephrotic syndrome is to manage severe edema, not to reduce fever, which might be managed by antipyretics if present.

Choice B rationale

Weight gain is typically undesirable in nephrotic syndrome patients due to fluid retention and edema. Albumin therapy aims to reduce edema, potentially decreasing weight as fluid balance improves.

Choice C rationale

Albumin infusion helps reduce edema by increasing plasma oncotic pressure, drawing fluid back into the vascular system. A reduction in edema indicates the therapy’s effectiveness in managing nephrotic syndrome symptoms.

Choice D rationale

Improved caloric intake is not directly affected by albumin infusion. While managing edema might improve overall well-being, albumin’s primary function in this context is fluid balance and reducing swelling.

A. Report the findings immediately to the healthcare provider. B. Obtain a swab of secretions from the penis and urethra. C. Provide the adolescent with a urinal for urinary hesitancy. D. Collect a sterile urine sample for culture and sensitivity.

Correct Answer is A

Explanation

Choice A rationale

Reporting the findings immediately to the healthcare provider is crucial in this scenario. Intense testicular pain with erythema and swelling can indicate testicular torsion, which is a medical emergency requiring prompt surgical intervention to preserve testicular function. Delays in treatment can result in loss of the affected testicle.

Choice B rationale

Obtaining a swab of secretions from the penis and urethra is not the immediate priority in this situation. While it can be important for diagnosing infections, the acute nature of the symptoms suggests a more urgent condition, such as testicular torsion, which needs immediate attention from a healthcare provider.

Choice C rationale

Providing the adolescent with a urinal for urinary hesitancy does not address the immediate concern of intense pain and significant swelling. The symptoms suggest a possible emergency, and addressing urinary hesitancy can wait until after more urgent conditions are ruled out or treated.

Choice D rationale

Collecting a sterile urine sample for culture and sensitivity is not the immediate priority. While it might be useful for diagnosing infections, the symptoms of intense pain, erythema, and swelling in the testicular area suggest an urgent condition like testicular torsion, which requires immediate evaluation and treatment.

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Which is the most important assessment for the nurse to conduct following the administration of epidural anesthesia to a client who is at 40-weeks gestation?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Albumin 25% IV is prescribed for a child with nephrotic syndrome. Which assessment finding indicates to the nurse that the medication is having the desired effect?

Correct Answer is C

Explanation

A male adolescent arrives at the clinic and reports intense pain in the testicular area that occurred during football practice at high school. The nurse observes the scrotum and identifies significant erythema and swelling. Which action should the nurse take?

Correct Answer is A

Explanation

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