A patient had an epidural inserted 2 hours ago. It is functioning well, the patient is stable, and labor is progressing
Which parts of the assessment have the highest priority? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Assess blood pressure every hour.
2. Assess the pulse rate every hour.
3. Palpate the bladder.
4. Auscultate the lungs.
5. Assess the reflexes.
1,3
Rationale 1: If blood pressure is stable, it should be assessed at least hourly, because the epidural can cause hypotension.
Rationale 2: This is done, but is not a priority.
Rationale 3: The patient loses the feeling and urge to urinate with an epidural.
Rationale 4: This done, but is not a first priority.
Rationale 5: Assessing reflexes is not a priority with an epidural.
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