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    Ati maternal newborn proctored exam

    A nurse is caring for a client who is receiving opioid epidural analgesia during labor. Which of the following findings is the nurse's priority?

    Explanation & Rationale

    A. The client reports weakness of the lower extremities: Lower extremity weakness is a possible side effect of epidural analgesia due to the temporary motor block. While this finding requires monitoring and may affect mobility or safety, it is not immediately life-threatening compared to hypotension. B. Blood pressure 80/56 mm Hg: Hypotension is a common and serious complication of epidural analgesia due to sympathetic blockade, which can decrease placental perfusion and compromise fetal oxygenation. This is the priority finding because it affects both maternal and fetal well-being and requires immediate intervention. C. Temperature 38.2°C (100.8°F):.While fever can occur with epidural analgesia or prolonged labor, it is not an immediate life-threatening emergency. It warrants further assessment for infection, but it does not take precedence over severe hypotension, which can compromise vital organ perfusion. D. The client reports perfuse itching: Itching (pruritus) is a known side effect of opioids, particularly when administered via the epidural route. While uncomfortable, it is not dangerous and can often be managed with medications like antihistamines if needed, making it a lower priority.

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