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.
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. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The client is a 4-month-old female with a history of gastroesophageal reflux (GERD). Client had fundoplication surgery and will be hospitalized for several days of recovery.
Based on the FLACC score and the client's developmental level, mark which nurse actions would be appropriate, and which would not be appropriate.
Each row must have one option selected.
Correct Answer is C
Explanation
Choice A rationale
Requesting extra staff to help with the nursing assessments may not be the most effective approach. It could increase the child's anxiety due to the presence of more unfamiliar people in the room. The primary goal is to create a calm environment that helps the child feel safe and more cooperative.
Choice B rationale
Explaining the reasons for the examination to the child may not be effective for a preschooler who may not fully understand or be comforted by such explanations. Young children often require more tangible and immediate means of reassurance and distraction.
Choice C rationale
Talking to the mother and gradually focusing on the child's toy is a practical approach. This strategy helps build rapport with both the mother and the child, and using the toy as a focal point can distract and comfort the child, making the examination process less intimidating and more cooperative.
Choice D rationale
Completing the assessment while allowing the child to cry may not be ideal. It can increase the child's distress and make the assessment more challenging. Addressing the child's emotional needs by providing comfort and distraction can lead to a more successful and less stressful examination.
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