QUESTION: "A 25-year-old woman who is in the first stage of labor receives a continuous lumbar epidural block when the cervix is 6 cm dilated. After administration of this anesthesia, which of the following assessments would be most important?"
CHOICES
( O ) a.) Fetal heart rate.
( X ) b.) Amniotic fluid color.
( X ) c.) Level of anesthesia.
( X ) d.) Level of consciousness.
RATIONALE: The anesthetic used for the epidural block may cause poor muscle tone and fetal hypoxia. A major complication is a decreased fetal heart rate. Thus, assessment of fetal heart rate is most important. Maternal effects of epidural anesthesia include hypotension and slowing of labor, necessitating a forceps delivery. The nurse should monitor fetal heart rate patterns, maternal blood pressure, pulse, and respirations every 5 minutes for at least 30 minutes after an epidural anesthetic and should report any drop in fetal heart rate or maternal blood pressure immediately. Epidural anesthesia has no effect on the status of the membranes or the color of the amniotic fluid. The membranes may rupture spontaneously or by amniotomy. The person responsible for administering the anesthesia would be responsible for determining the level of anesthesia. Although some clients may sleep after an epidural, the client normally remains conscious while under the influence of regional anesthesia, such as an epidural block. Assessing the level of consciousness, although important for any client, is not the priority following epidural anesthesia. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
