Which of the following findings indicates that epidural treatment is effective for a client who is receiving it for continuous labor analgesia?
The client has bladder distention.
The client reports slight pressure with contractions.
The client is unable to move their legs or feet.
The client's systolic blood pressure decreases by 20 mm Hg.
The Correct Answer is B
Choice A reason: Bladder distention indicates an adverse effect of epidural analgesia, as nerve blockade impairs bladder sensation, leading to retention. This is not a sign of effective pain relief but a complication requiring monitoring or catheterization to prevent urinary tract infections or bladder overdistension, per epidural side effect management.
Choice B reason: Reporting slight pressure with contractions indicates effective epidural analgesia, as it reduces pain while preserving some sensation, allowing awareness of labor progress. This reflects targeted nerve blockade, alleviating visceral pain via opioid and anesthetic action, aligning with the goal of balanced labor analgesia without complete sensory loss.
Choice C reason: Inability to move legs or feet suggests excessive epidural blockade, a complication rather than effective analgesia. Optimal epidurals provide pain relief with minimal motor impairment, allowing mobility. Complete paralysis risks prolonged recovery or injury, not reflecting the therapeutic goal of labor pain management, per anesthesia protocols.
Choice D reason: A 20 mm Hg systolic blood pressure decrease indicates hypotension, an adverse effect of epidural analgesia due to sympathetic blockade. This risks reduced placental perfusion, not effective pain relief. It requires intervention like fluids, contrary to the goal of stable analgesia with minimal maternal or fetal impact.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Dark, concentrated urine in a 5-day-old newborn indicates inadequate milk intake, as effective breastfeeding produces pale, dilute urine due to sufficient hydration. Breast milk provides water and nutrients, supporting renal function and urine output. This finding suggests dehydration, requiring intervention to ensure adequate feeding and prevent neonatal metabolic complications.
Choice B reason: Expecting only two to three wet diapers in 24 hours is inadequate for a 5-day-old breastfed newborn. Effective breastfeeding results in six to eight wet diapers daily, reflecting sufficient milk intake and hydration. Low diaper counts indicate poor feeding, risking dehydration and weight loss, which does not align with successful breastfeeding physiology.
Choice C reason: A tugging sensation during breastfeeding indicates effective latch and suckling, ensuring milk transfer. This sensation reflects the infant’s strong suck, stimulating milk ejection via oxytocin release. Proper latch promotes adequate nutrition and hydration, supporting neonatal growth and preventing dehydration, aligning with the physiological mechanics of successful breastfeeding.
Choice D reason: Breasts staying firm after breastfeeding suggests incomplete milk transfer, indicating ineffective feeding. Effective breastfeeding softens breasts due to milk removal, stimulated by infant suckling and oxytocin-mediated letdown. Firm breasts may signal poor latch or insufficient feeding frequency, risking engorgement or reduced milk supply, contrary to successful breastfeeding outcomes.
Correct Answer is D
Explanation
Choice A reason: Stating that rubella vaccination prevents breastfeeding is incorrect. The rubella vaccine, a live-attenuated virus, is safe for postpartum administration in non-immune mothers, as it does not significantly excrete in breast milk or harm the infant. Breastfeeding supports neonatal immunity through maternal antibodies, and this statement misrepresents vaccine safety and breastfeeding physiology.
Choice B reason: Repeating a rubella titer in the third trimester is unnecessary unless new exposure is suspected. A titer of 1:8 indicates susceptibility, requiring postpartum immunization, not repeated testing. Serological testing monitors antibody levels, but rubella immunity status typically remains stable during pregnancy unless infection occurs, making routine retesting scientifically unjustified in this context.
Choice C reason: Administering rubella immunization during pregnancy is contraindicated, as it is a live vaccine that poses a theoretical risk to the fetus. A titer of 1:8 indicates susceptibility, warranting postpartum vaccination. The immune system’s response to live vaccines could potentially cross the placenta, affecting fetal development, so immunization is deferred until after delivery.
Choice D reason: A rubella titer of 1:8 indicates susceptibility, as titers below 1:10 suggest insufficient antibodies to confer immunity. Rubella infection during pregnancy can cause congenital rubella syndrome, leading to fetal anomalies. This statement accurately reflects the need for postpartum immunization to protect future pregnancies, aligning with serological evidence and prenatal care guidelines.
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