Which of the following findings should the nurse recognize and document as an adverse effect of epidural analgesia for a client who is in labor?

Choice A reason: Administering an IV bolus of lactated Ringer’s is not indicated for preeclampsia without severe features, as fluid overload can exacerbate hypertension or pulmonary edema. P ओपेक्शिया involves endothelial dysfunction, and excessive fluids may worsen vascular leakage. Blood pressure and symptom monitoring are prioritized over fluid administration in non-severe cases.

Choice B reason: Misoprostol is used for labor induction or postpartum hemorrhage, not preeclampsia management. Preeclampsia requires blood pressure control and seizure prophylaxis, not cervical ripening agents. Misoprostol’s prostaglandin effects are irrelevant to preeclampsia’s pathophysiology, which involves vasoconstriction and endothelial damage, making this medication inappropriate for the condition’s treatment.

Choice C reason: Assessing blood pressure twice daily is insufficient for preeclampsia, even without severe features, as it requires frequent monitoring (every 4-6 hours) to detect progression to severe hypertension. Preeclampsia can rapidly worsen due to vascular instability, and infrequent checks risk missing critical changes, compromising maternal and fetal safety.

Choice D reason: Assessing for edema is essential in preeclampsia, as it reflects vascular leakage from endothelial dysfunction. Edema, especially in the face or hands, signals worsening disease, necessitating closer monitoring or intervention. This assessment tracks fluid retention, a key pathophysiological feature of preeclampsia, aiding in early detection of progression to severe features.

Choice A reason: Covering the baby’s eyes during biliblanket use is unnecessary, as the device emits low-intensity light focused on the skin, not the eyes. Unlike overhead phototherapy, biliblankets pose minimal risk of retinal damage. Eye protection is reserved for high-intensity light exposure, per neonatal jaundice treatment guidelines.

Choice B reason: Offering glucose water after feedings is not recommended, as breast milk or formula provides adequate hydration and nutrition. Glucose water may disrupt feeding cues and reduce milk intake, potentially worsening jaundice by limiting caloric support for liver conjugation of bilirubin, per neonatal nutritional recommendations.

Choice C reason: Checking bilirubin levels every 6 hours at home is impractical, as it requires laboratory testing. Home phototherapy relies on periodic provider-ordered tests, typically daily or less, to monitor jaundice. Frequent checks are unnecessary and infeasible for parents, as bilirubin metabolism is managed through consistent phototherapy exposure.

Choice D reason: Removing the baby from the biliblanket for feedings is appropriate, as it ensures adequate nutrition and bonding without significantly interrupting phototherapy. Bilirubin breakdown continues with intermittent exposure, and feedings support liver function by enhancing bilirubin excretion, aligning with neonatal jaundice management and nutritional needs.