A nurse is collecting data from a client who is receiving epidural anesthesia.Which of the following findings indicates an adverse effect of this method of pain management?
Hypertension.
Tachypnea.
Tachycardia.
Fever.
The Correct Answer is D
Choice A rationale
Hypertension is not a common adverse effect of epidural anesthesia. In fact, epidurals can cause hypotension due to the blockade of sympathetic nerves.
Choice B rationale
Tachypnea is not typically associated with epidural anesthesia. Common side effects include low blood pressure and headache.
Choice C rationale
Tachycardia is not a common adverse effect of epidural anesthesia. More common side effects include low blood pressure and urinary retention.
Choice D rationale
Fever is a known adverse effect of epidural anesthesia. It can occur due to the body’s response to the epidural procedure.
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Correct Answer is D
Explanation
Choice A rationale
Purchasing furniture for the baby’s room is a common and healthy behavior during pregnancy. It indicates that the client is preparing for the baby’s arrival and is excited about the new addition to the family. This behavior is generally seen as positive and supportive of the pregnancy.
Choice B rationale
Being unsure about wanting an epidural during labor is a normal concern for many pregnant individuals. It reflects the client’s consideration of pain management options and their desire to make an informed decision. This is not typically seen as a psychosocial concern.
Choice C rationale
The partner planning to attend birthing classes with the client is a positive sign of support and involvement in the pregnancy. It indicates that the partner is engaged and willing to participate in the childbirth process, which can be beneficial for the client’s emotional well-being.
Choice D rationale
Expressing uncertainty about whether an older child will accept the new baby can indicate underlying anxiety or stress about family dynamics and the impact of the new baby on existing relationships. This concern may require further exploration and support to ensure the client’s emotional health.
Correct Answer is B
Explanation
Choice A rationale
Placing the newborn supine and applying pressure to the soles of the feet is not the correct method to elicit the Babinski reflex. This action does not stimulate the appropriate nerve pathways involved in the reflex.
Choice B rationale
Stroking upward on the lateral aspect of the sole of the newborn’s foot is the correct method to elicit the Babinski reflex. This action stimulates the plantar reflex, causing the big toe to extend upward and the other toes to fan out.
Choice C rationale
Pulling the newborn up by the wrist from a supine position is used to elicit the traction response, not the Babinski reflex. The traction response involves the newborn flexing their arms and attempting to lift their head.
Choice D rationale
Touching the corner of the newborn’s mouth elicits the rooting reflex, not the Babinski reflex. The rooting reflex causes the newborn to turn their head toward the stimulus and open their mouth.