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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 B

Explanation

Choice A rationale

The presenting part being 2 cm below the ischial spines would be documented as +2 station, indicating that the fetal head is descending well into the pelvis.

Choice B rationale

The presenting part being 2 cm above the ischial spines is correctly documented as -2 station. This indicates that the fetal head is still relatively high in the pelvis and has not yet descended to the level of the ischial spines.

Choice C rationale

The presenting part being at the level of the ischial spines is documented as 0 station. This is the midpoint of the pelvis and indicates that the fetal head is engaged.

Choice D rationale

The presenting part being 2 cm below the cervix is not a standard way to describe fetal station. Station is measured relative to the ischial spines, not the cervix.

Correct Answer is B

Explanation

Choice A rationale

Category I tracings are considered normal and are associated with a well-oxygenated, non-acidotic fetus with a normal fetal heart rate baseline, moderate variability, and no late or variable decelerations. However, a baseline heart rate of 175 bpm is considered tachycardia, which does not fit the criteria for Category I.

Choice B rationale

Category II tracings are indeterminate and include any fetal heart rate pattern that does not fit into Category I or III. A baseline heart rate of 175 bpm with moderate variability and no accelerations or decelerations fits into this category. This indicates that the fetus may be experiencing some stress but is not in immediate danger.

Choice C rationale

Category III tracings are abnormal and are associated with an increased risk of fetal acidemia. These tracings include absent baseline variability with recurrent late or variable decelerations, bradycardia, or a sinusoidal pattern. The given tracing does not meet these criteria as it shows moderate variability and no decelerations.

Choice D rationale

There is no Category IV in the classification of fetal heart rate tracings. The standard classification includes only Categories I, II, and III.

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