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
Uterine contractions that cause variable decelerations are not specific to true labor. Variable decelerations are typically associated with umbilical cord compression and can occur during both true and false labor.
Choice B rationale
Regular uterine contractions that cause cervical change are a definitive sign of true labor. True labor is characterized by contractions that become progressively stronger, more frequent, and more regular, leading to cervical dilation and effacement. This process indicates that the body is preparing for childbirth.
Choice C rationale
The station of the presenting part refers to the position of the fetus in relation to the ischial spines of the pelvis. While it is an important aspect of labor progression, it is not a definitive sign of true labor.
Choice D rationale
Rupture of the membranes, or the breaking of the water, can occur before true labor begins. While it often indicates that labor is imminent, it is not a definitive sign of true labor on its own.
Correct Answer is D
Explanation
Choice A rationale
Early decelerations are not caused by umbilical cord compression. Umbilical cord compression typically leads to variable decelerations, which have a different pattern and clinical significance.
Choice B rationale
Early decelerations are not caused by uteroplacental insufficiency. Uteroplacental insufficiency is associated with late decelerations, which occur after the peak of a contraction and indicate reduced blood flow to the fetus.
Choice C rationale
Early decelerations are not a result of the administration of medications. Medications can affect fetal heart rate patterns, but early decelerations are specifically related to fetal head compression.
Choice D rationale
Early decelerations are related to fetal head compression. They occur as the fetal head descends into the maternal pelvis and are generally considered benign, indicating normal labor progression.