A client had an epidural inserted 2 hours ago. It is functioning well, the client is stable, and labor is progressing
Which parts of the nurse's 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
Explanation: 1. Blood pressure should be monitored every 1 to 2 minutes for the first 10 minutes and then every 5 to 15 minutes until the block wears off because hypotension is the most common side effect of epidural anesthesia.
3. Nursing care following an epidural block includes frequent assessment of the bladder to avoid bladder distention. Catheterization may be necessary, because most women are unable to void.
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