# A pregnant woman at 39 weeks gestation is receiving epidural anesthesia during labor. Which assessment finding requires the nurse's immediate intervention?

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> url: https://mymerci.kr/pages/nclex_q.php?qn_id=543011  
> language: ko  
> subject: Maternal Newborn Health

## 문제

A pregnant woman at 39 weeks gestation is receiving epidural anesthesia during labor. Which assessment finding requires the nurse's immediate intervention?

## 보기

1. Maternal blood pressure 118/76 mmHg
2. Fetal heart rate 140-150 bpm with moderate variability
3. Maternal temperature 99.2°F (37.3°C)
4. Maternal blood pressure 88/50 mmHg with dizziness **✔ 정답**

**정답: 4**

## 해설

Maternal hypotension (88/50 mmHg with dizziness) is a critical complication of epidural anesthesia requiring immediate intervention to prevent uteroplacental compromise. Other findings are within normal limits and do not need urgent action.

## 심화 해설

Understanding the Clinical Scenario

This question presents a common intrapartum nursing scenario. A patient at term is receiving epidural anesthesia, a neuraxial technique that provides effective labor analgesia. The core nursing responsibility is continuous monitoring for complications, which often stem from the procedure's predictable physiological effects. The most critical of these is the sympathetic blockade caused by the local anesthetic.

Analyzing the Assessment Findings

To identify the finding requiring immediate intervention, we must link the pathophysiology of epidural anesthesia to each assessment option.

Option 1: Maternal blood pressure 118/76 mmHg

This blood pressure reading is within normal limits for a pregnant woman at term. While monitoring for hypotension is essential, this finding is reassuring and does not require intervention.

Option 2: Fetal heart rate 140-150 bpm with moderate variability

A fetal heart rate baseline of 140 to 150 bpm is within the normal range (110-160 bpm). The presence of moderate variability is a key indicator of fetal well-being, reflecting an intact and adequately oxygenated fetal central nervous system. This is a normal, reassuring finding.

Option 3: Maternal temperature 99.2°F (37.3°C)

A temperature of 99.2°F (37.3°C) is a low-grade elevation. Epidural anesthesia is known to be associated with a gradual rise in maternal temperature, likely due to altered thermoregulation. While this finding should be monitored and documented, it does not represent an immediate threat to maternal or fetal safety compared to acute hypotension.

Option 4: Maternal blood pressure 88/50 mmHg with dizziness

This is the critical finding. Epidural anesthesia blocks sympathetic nerve fibers along with sensory fibers. This sympathetic blockade causes vasodilation in the lower extremities, leading to a relative hypovolemia and a sudden drop in systemic vascular resistance. The result is maternal hypotension, defined as a systolic blood pressure below 100 mmHg or a 20% decrease from baseline . The patient's blood pressure of 88/50 mmHg, accompanied by the subjective symptom of dizziness, is a classic presentation of this complication. The immediate danger is two-fold: maternal compromise from hypoperfusion and, more critically, fetal compromise from reduced uteroplacental perfusion. This situation demands immediate nursing intervention, such as repositioning the patient to a left lateral position, increasing the rate of intravenous fluid administration, administering oxygen, and notifying the anesthesia provider for potential vasopressor administration, as the study by Czyżewski et al. highlights the need to manage these hemodynamic changes to ensure maternal and fetal safety .

Connecting to NCLEX-RN Priority Setting

This question tests your ability to apply the nursing process and prioritize care using a physiological framework. The NCLEX-RN exam frequently uses assessment findings to test your knowledge of complications from common procedures. Hypotension is the most common serious complication of epidural anesthesia. While a post-dural puncture headache (PDPH) is a well-known complication, its onset is typically delayed, occurring 24-72 hours after the procedure, and it does not present as an acute hypotensive crisis during labor . The immediate, life-threatening risks are from acute hemodynamic instability. Recognizing the hypotensive crisis and understanding its direct link to uteroplacental insufficiency allows you to immediately identify the most dangerous finding and act to prevent fetal hypoxia and maternal injury.

## 임상 시나리오

Clinical Scenario

A 39-week gravid patient on epidural anesthesia develops a blood pressure of 88/50 mmHg and reports dizziness. The nurse recognizes this as a classic presentation of epidural-induced hypotension from sympathetic blockade.

Immediate Nursing Actions

- **Activate the chain of command** – notify the anesthesia provider and obstetrician simultaneously while initiating bedside interventions.

- **Position the patient** in full left lateral tilt or complete lateral decubitus to displace the gravid uterus off the vena cava and augment venous return.

- **Administer a bolus** of intravenous crystalloid (e.g., 500-1000 mL Lactated Ringer's) via rapid infusion as ordered or per protocol to expand intravascular volume.

- **Apply supplemental oxygen** at 10 L/min via non-rebreather mask to maximize fetal oxygenation during the hypotensive episode.

- **Prepare vasopressor support** – ephedrine (5-10 mg IV push) or phenylephrine as first-line agents per unit protocol if fluid resuscitation alone does not restore normotension.

Ongoing Monitoring Priorities

- Reassess maternal blood pressure every 1-2 minutes until stable, then every 5-15 minutes per protocol.

- Continuously evaluate fetal heart rate tracing for late decelerations, bradycardia, or loss of variability indicating fetal distress from uteroplacental hypoperfusion.

- Monitor maternal level of consciousness and document any persistent nausea, tinnitus, or visual disturbances that may herald worsening hypotension.

- Assess the sensory level of the epidural block to rule out high or total spinal anesthesia if hypotension is refractory.

Pathophysiology Rationale

Epidural local anesthetics block sympathetic fibers (T1-L2) along with sensory fibers. Loss of vasomotor tone in the splanchnic and lower extremity vasculature causes venous pooling and decreased systemic vascular resistance. In the term gravid patient, aortocaval compression by the uterus further reduces preload, making profound hypotension a high-risk event. A maternal systolic blood pressure below 100 mmHg or a 20% decrease from baseline compromises uteroplacental perfusion pressure, placing the fetus at immediate risk for hypoxic injury.

## 핵심 개념

- **Sympathetic Blockade** — Loss of sympathetic nervous system tone caused by local anesthetic spread during epidural or spinal anesthesia, leading to vasodilation and potential hypotension.
- **Uteroplacental Hypoperfusion** — Reduced blood flow to the uterus and placenta, often secondary to maternal hypotension, which can compromise fetal oxygenation.
- **Epidural Anesthesia** — A neuraxial analgesic technique involving injection of local anesthetic into the epidural space to block nerve roots, commonly used for labor pain relief.
- **Moderate Variability** — Fluctuations in the fetal heart rate baseline of 6 to 25 beats per minute, indicating a well-oxygenated and intact fetal central nervous system.
- **Intrapartum Nursing** — Nursing care provided to a woman and her fetus during the labor and birth process, focusing on continuous assessment and early recognition of complications.

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