A nurse is assessing a client in labor who has had epidural anesthesia for pain relief. Which of the following findings should the nurse identify as a complication from the epidural block?

Correct Answer: D

Rationale: Epidural anesthesia can cause hypotension as a common complication. This occurs because the local anesthetic affects the sympathetic nerves, leading to vasodilation and subsequent lowering of blood pressure. It is crucial for nurses to monitor the client's blood pressure closely and be prepared to administer IV fluids or medications to address the hypotension promptly. Vomiting, tachycardia, and respiratory depression are not typically associated with epidural anesthesia; therefore, hypotension is the most likely complication to be identified in this scenario.

Correct Answer: D

Rationale: The order that the nurse should question is "Ampicillin 200mg./kg IV every 6 hours." The usual dosage for ampicillin is 200-300 mg/kg/day divided into 4-6 doses, not every 6 hours. Administering ampicillin every 6 hours at 200mg/kg could potentially lead to overdose for the neonate. It is important to clarify this dosage with the health care provider before administering the medication to ensure the safety of the newborn.

Correct Answer: D

Rationale: In the scenario of a postpartum mother reporting a severe headache, the immediate action the nurse should take is to notify the healthcare provider immediately (Option D). This is the correct choice because a severe headache postpartum could be indicative of serious conditions such as postpartum preeclampsia or postpartum hemorrhage, both of which require prompt medical attention. Administering analgesics and monitoring blood pressure (Option A) could mask important symptoms and delay the necessary medical evaluation. Encouraging the mother to rest (Option B) is not appropriate when a severe headache could be a sign of a potentially life-threatening condition. Applying a cold compress (Option C) may provide temporary relief but does not address the underlying cause of the severe headache. In an educational context, it is crucial for nurses to recognize the potential complications that can arise postpartum and to prioritize prompt communication with healthcare providers when patients present with concerning symptoms. This case emphasizes the importance of timely assessment and intervention in the postpartum period to ensure the well-being of both the mother and the newborn.

Correct Answer: A

Rationale: In the context of a newborn with a temperature of 35.5°C (95.9°F), the priority nursing action is to place the newborn under a radiant warmer (Option A). This is because newborns have limited ability to regulate their body temperature, and hypothermia can lead to serious complications such as respiratory distress, hypoglycemia, and metabolic acidosis. Placing the newborn under a radiant warmer helps to prevent further heat loss and stabilize the infant's temperature. Administering warm IV fluids (Option B) is not the priority in this situation as direct warming of the newborn is more effective in addressing hypothermia. Swaddling the newborn in warm blankets (Option C) may provide some insulation but may not be sufficient to rapidly raise the infant's temperature. Providing glucose supplementation (Option D) is not indicated as the primary concern in this scenario is to address the hypothermia promptly to prevent further complications. In an educational context, understanding the significance of maintaining newborn thermoregulation is crucial for nursing practice in maternal newborn care. Nurses need to be able to recognize signs of hypothermia in newborns and take prompt action to address it, as even mild hypothermia can have detrimental effects on a newborn's health and wellbeing. Placement under a radiant warmer is a standard intervention to stabilize the newborn's temperature quickly and prevent complications associated with hypothermia.

Correct Answer: B

Rationale: In the context of a mother receiving magnesium sulfate therapy, the primary nursing concern is to monitor deep tendon reflexes hourly. This is crucial because magnesium sulfate is a central nervous system depressant used to prevent seizures in pre-eclampsia and eclampsia. Monitoring deep tendon reflexes helps assess the level of neuromuscular blockade caused by magnesium sulfate. Decreased or absent reflexes indicate drug toxicity, which can progress to respiratory depression, cardiac arrest, and maternal death if not promptly addressed. Monitoring blood pressure every 4 hours (Option A) is important in pre-eclampsia but is not the primary concern when a mother is on magnesium sulfate therapy. Assessing respiratory rate and effort (Option C) is essential but not the primary concern compared to monitoring deep tendon reflexes. Preparing for delivery if signs of toxicity appear (Option D) is important but is an action taken after recognizing toxicity, not the primary concern for ongoing monitoring. Educationally, understanding the rationale behind closely monitoring deep tendon reflexes while a mother is on magnesium sulfate therapy reinforces the importance of pharmacological knowledge in maternal care. It emphasizes the critical role nurses play in assessing and managing potential medication side effects to ensure optimal maternal and fetal outcomes.