The nurse is caring for a client immediately after epidural. Which of the following findings should the nurse report to the anesthesia provider?
Dizziness.
Blood pressure 88/52 mmHg.
Pain of 1 on a 0 to 10 scale.
Pulse 88 bpm.
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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Correct Answer is B
Explanation
Choice A rationale
Providing ice chips or mouth swabs can help keep the client comfortable and hydrated, but it is not the priority action when administering pain medication.
Choice B rationale
Assessing and documenting maternal vital signs and fetal heart rate after administering Fentanyl is crucial. This ensures that the medication is not causing any adverse effects on the mother or fetus and that both are stable.
Choice C rationale
Dimming the lights and providing a quiet atmosphere can help create a calming environment, but it is not the priority action when administering pain medication.
Choice D rationale
Assisting the patient with coping skills, including breathing techniques, is important for managing pain, but it is not the priority action when administering pain medication.
Correct Answer is A
Explanation
Choice A rationale
Late decelerations are a sign of uteroplacental insufficiency and fetal hypoxia. They occur after the peak of a contraction and indicate that the fetus is not receiving enough oxygen. This requires immediate intervention to improve fetal oxygenation and prevent fetal distress.
Choice B rationale
Variability in fetal heart rate of 12 bpm is considered moderate variability, which is a reassuring sign of fetal well-being. It indicates that the fetus has a healthy autonomic nervous system and is not in distress.
Choice C rationale
Accelerations in fetal heart rate are also a reassuring sign. They indicate that the fetus is well-oxygenated and responding appropriately to stimuli. No intervention is needed for accelerations.
Choice D rationale
A baseline fetal heart rate of 140 bpm is within the normal range (110-160 bpm) and does not indicate any immediate concern. It is a sign of a healthy, well-oxygenated fetus.