A patient receives an epidural anesthesia during the first stage of labor. The epidural is discontinued immediately after delivery. The patient is at an increased risk of which problem during the fourth stage of labor?

Correct Answer: A

Rationale: When a patient receives an epidural anesthesia during the first stage of labor, it can lead to temporary bladder dysfunction. The epidural can affect the patient's ability to feel the sensation of a full bladder and may impair the ability to voluntarily urinate. If the epidural is discontinued immediately after delivery during the fourth stage of labor, the patient may be at an increased risk of bladder distention due to the residual effects of the epidural. Therefore, monitoring for bladder distention and ensuring adequate bladder emptying is important to prevent complications.

Correct Answer: A

Rationale: The most important nursing action to undertake at this time is obtaining a fetal heart rate (FHR) assessment. Monitoring the FHR is crucial during labor to assess the well-being of the baby and detect any signs of fetal distress. This information helps guide the healthcare team in determining the appropriate course of action to ensure the safety of both the mother and baby. It takes precedence over other tasks such as completing a sterile vaginal exam, assessing the odor of amniotic fluid, performing Leopold's maneuver, or obtaining pain medication orders. Monitoring the FHR should be the immediate priority in this situation.

Correct Answer: A

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.

Correct Answer: B

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.

Correct Answer: A

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.