Health Promotion and Maintenance
68. A client, who is gravida 3, para 2 at 37 weeks' gestation, is 5 cm dilated, 80% effaced, and a +1 station. She received epidural anesthesia with bupivacaine hydrochloride (Marcaine) for contraction pain 1 hour ago. Which nursing assessment is most important for this client at this time?
. Assessing the client hourly for respiratory depression.
. Assessing the client hourly for uterine atony.
. Assessing the client hourly for bladder distention.
. Assessing the client hourly for hypertension.
Test-Taking Tip
All the answers involve assessment on an hourly basis; therefore, focus on the differences between the alternatives. Eliminate the three options that are not an effect of epidural anesthesia.
Content Area: Maternity, Intrapartum; Integrated Process: Nursing Process, Assessment; Cognitive Level: Analysis; Client Need/Subneed: Physiological Integrity/Pharmacological and Parenteral Therapies/Expected Effects/Outcomes
Health Promotion and Maintenance
.
Answer 1 is incorrect because Marcaine is an anesthetic agent and does not cause respiratory depression. Respiratory depression is associated with epidural narcotics. Answer 2 is incorrect because uterine atony is not an effect of epidural anesthesia. Answer 3 is correct because the client may not sense the urge to void due to decreased sensation to the area. Bladder distention can interfere with descent of the fetus and cause pain. Answer 4 is incorrect because maternal hypotension, not hypertension, is a side effect of epidural anesthesia.