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    Hesi rn compass exit proctored exam
    Select All That Apply

    A nurse is caring for a 26-year-old female client who is in active labor in the labor and delivery unit. The client has requested epidural anesthesia, and it has been administered to manage her pain during labor. The nurse is now monitoring her condition closely. Exhibits Select the 3 findings that would require immediate action from the nurse while the laboring mother is receiving epidural anesthesia.

    Explanation & Rationale

    Choice A rationale: Fetal decelerations require immediate action because they indicate potential fetal distress. Continuous fetal monitoring is essential to assess the fetus's well-being, and any signs of distress must be addressed promptly to ensure a safe delivery. Choice E rationale: Hypotension is a common side effect of epidural anesthesia and can lead to decreased blood flow to the fetus. Immediate intervention, such as administering IV fluids or medications, is necessary to stabilize the mother's blood pressure and ensure adequate fetal perfusion. Choice F rationale: Difficulty breathing is a critical sign that may indicate a severe reaction to the epidural anesthesia or other complications. Immediate assessment and intervention are required to ensure the mother's respiratory status is stable and to address any underlying issues. Choice B rationale: Reports of pain, while important, do not require immediate emergency action compared to the other findings. Pain management should be adjusted accordingly, but it does not pose an immediate threat to the mother or fetus. Choice C rationale: Nausea, while uncomfortable, is a common side effect of epidural anesthesia and does not require immediate emergency intervention. It can be managed with antiemetic medications. Choice D rationale: Dizziness can be a side effect of epidural anesthesia or hypotension, but it is not as critical as the other findings that require immediate emergency attention. It should be monitored and addressed as part of overall care.

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