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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

Encouraging the client to continue pushing is not appropriate at this stage. The client is 9 cm dilated, which indicates that she is in the transition phase of labor, not yet fully dilated and ready to push. Pushing at this stage could cause cervical swelling and delay progress.

Choice B rationale

Preparing the client for delivery is the most appropriate action. The client is in the transition phase of labor, with 9 cm dilation, 100% effacement, and +1 station. This indicates that delivery is imminent, and the nurse should prepare for the birth process.

Choice C rationale

Administering pain relief as prescribed may be considered, but it is not the priority action at this stage. The client is in the transition phase, and administering pain relief could interfere with the natural progression of labor. Non-pharmacological support may be more appropriate.

Choice D rationale

Reassuring the client and providing emotional support is important, but it is not the primary action at this stage. The nurse should focus on preparing for delivery while also providing support and reassurance.

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