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The nurse is caring for a client immediately after epidural. Which of the following findings should the nurse report to the anesthesia provider?

A.

Dizziness.

B.

Blood pressure 88/52 mmHg.

C.

Pain of 1 on a 0 to 10 scale.

D.

Pulse 88 bpm.

Answer and Explanation

The Correct Answer is B

Choice A rationale

 

Dizziness can be a side effect of epidural anesthesia, but it is not as critical as hypotension. It should be monitored, but it does not require immediate reporting unless it is severe or accompanied by other symptoms.

 

Choice B rationale

 

Blood pressure of 88/52 mmHg indicates hypotension, which is a common and potentially serious side effect of epidural anesthesia. Hypotension can lead to decreased placental perfusion and fetal distress, so it requires immediate attention and reporting to the anesthesia provider.

 

Choice C rationale

 

A pain level of 1 on a 0 to 10 scale indicates that the epidural is effectively managing the client’s pain. This is a positive outcome and does not require reporting.

 

Choice D rationale

 

A pulse of 88 bpm is within the normal range for an adult and does not indicate any immediate concern that needs to be reported to the anesthesia provider.

 


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View Related questions

Correct Answer is A

Explanation

Choice A rationale

This statement is incorrect because Stage 2 of labor does not involve the delivery of the placenta. Stage 2 starts with the complete dilation and effacement of the cervix and ends with the delivery of the fetus. The delivery of the placenta occurs in Stage 3 of labor.

Choice B rationale

This statement is correct. Stage 2 of labor begins with complete effacement and dilation of the cervix. This stage is characterized by the mother pushing and the eventual delivery of the baby.

Choice C rationale

This statement is also correct. Stage 2 starts when the cervix is fully dilated, allowing the mother to start pushing. This stage continues until the baby is born.

Choice D rationale

This statement is incorrect. Stage 2 ends with the delivery of the fetus, not the placenta. The delivery of the placenta is part of Stage 3 of labor.

Correct Answer is A

Explanation

Choice A rationale

  • Thenon-stress test (NST)is reactive, indicating normal fetal heart rate patterns with adequate accelerations.
  • Theultrasoundshows normal amniotic fluid index and fetal movements, with no abnormalities detected.
  • The client has no significant medical history and is generally feeling well.

These findings suggest that the fetus is currently well, and there is no immediate need for further intervention. However, the client should be instructed to monitor fetal movements at home and return if there are any concerns or if decreased fetal movement persists. This approach balances the need for vigilance with the reassurance provided by the normal test results.

.

Choice B rationale

Continuous fetal monitoring is typically reserved for cases where there is a significant concern for fetal distress or other complications. In this case, both the non-stress test (NST) and ultrasound results are normal, indicating that the fetus is currently well. Therefore, continuous monitoring in a hospital setting is not necessary.

Choice C rationale

An immediate cesarean section is a major surgical procedure that is usually performed when there is an urgent risk to the mother or baby. Given the normal NST and ultrasound findings, there is no indication of fetal distress or other complications that would warrant such an intervention at this time.

Choice D rationale

Corticosteroids are given to enhance fetal lung maturity in cases where preterm delivery is anticipated, typically before 34 weeks of gestation. Since the client is already at 35 weeks and there is no indication of imminent preterm labor or other complications, administering corticosteroids is not necessary..

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