A laboring client has just received an epidural.
Ten minutes after the epidural placement, the client begins to feel dizzy and lightheaded and the BP is 92/54. What should be the nurse’s first response?
Perform a vaginal examination.
Turn the client onto her side.
Catheterize the client.
Decrease the IV fluid rate.
The Correct Answer is B
Choice A rationale:
Performing a vaginal exam is not the priority intervention for a client experiencing hypotension after an epidural. While a vaginal exam may be necessary to assess cervical dilation and fetal station, it does not address the underlying cause of the client's hypotension.
Additionally, a vaginal exam could potentially worsen the client's hypotension by stimulating the vagus nerve, which can lead to decreased heart rate and blood pressure.
Therefore, it is not the most appropriate initial response in this situation.
Choice B rationale:
Turning the client onto her side is the most appropriate initial response to hypotension after an epidural. This position helps to increase venous return to the heart, which can improve cardiac output and blood pressure.
It also helps to prevent aortocaval compression, which can occur when the pregnant uterus compresses the inferior vena cava, reducing blood flow back to the heart.
By turning the client onto her side, the nurse can quickly and easily address the underlying cause of the hypotension and help to improve the client's hemodynamic status.
Choice C rationale:
Catheterizing the client may be necessary if the client is unable to void spontaneously, but it is not the priority intervention for hypotension after an epidural.
Urinary retention can occur after an epidural, but it is not typically the cause of hypotension in this setting.
Therefore, catheterization would not be the most appropriate initial response.
Choice D rationale:
Decreasing the IV fluid rate may be necessary if the client is experiencing fluid overload, but it is not the priority intervention for hypotension after an epidural.
In fact, decreasing the IV fluid rate could potentially worsen the hypotension by reducing the circulating blood volume.
Therefore, it is not the most appropriate initial response.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Fetal position during the first trimester is not definitively determined through ultrasound. While the gestational sac and fetal pole can be visualized, the fetus is still quite small and has ample space to move within the amniotic sac. This makes it challenging to accurately ascertain its position.
Reliable assessment of fetal position typically occurs later in pregnancy, usually between 34 and 36 weeks gestation. At this point, the fetus is larger and less mobile, allowing for a clearer assessment of its position through ultrasound.
The early determination of fetal position in the first trimester is not a primary goal of ultrasound. It is more focused on establishing pregnancy viability, gestational age, and detecting any potential abnormalities.
Choice B rationale:
Ultrasound in the first trimester can reliably detect multiple gestations. It can visualize the presence of multiple gestational sacs or fetal poles, clearly indicating whether a woman is carrying twins, triplets, or more.
Early identification of multiple gestations is crucial for optimal pregnancy management. It allows healthcare providers to tailor prenatal care, monitor for potential complications associated with multiple pregnancies, and plan for appropriate delivery. Choice C rationale:
Ultrasound in the first trimester can assist in detecting certain maternal abnormalities that could impact pregnancy. These may include:
Uterine abnormalities, such as fibroids or structural defects
Ovarian cysts
Ectopic pregnancies (where the embryo implants outside the uterus)
Gestational trophoblastic disease (abnormal growth of tissue inside the uterus)
Early identification of these maternal abnormalities allows for timely intervention and management, ensuring the best possible outcomes for both mother and fetus.
Choice D rationale:
Confirming pregnancy is a primary reason for ultrasound in the first trimester. It can visualize the gestational sac, which contains the developing embryo and confirms the presence of a pregnancy.
Ultrasound can also detect the fetal heartbeat, which typically becomes visible between 6 and 8 weeks gestation. This provides further confirmation of a viable pregnancy.
Correct Answer is C
Explanation
Choice A rationale:
This statement suggests that the patient has some awareness of infertility treatments, but it does not necessarily indicate a full understanding of infertility itself.
It's important to consider that a few months of trying to conceive may not be indicative of infertility, as it can take up to a year for healthy couples to achieve pregnancy.
Jumping to fertility treatments without a proper evaluation could lead to unnecessary interventions and potential financial and emotional burdens.
Choice B rationale:
This statement is incorrect. Male factor infertility is a common cause of difficulty conceiving, accounting for about 40% of infertility cases.
It's essential to evaluate both partners when assessing fertility issues.
Choice C rationale:
This statement demonstrates the patient's understanding of the relationship between age and fertility.
Female fertility gradually declines with age, especially after the age of 35, due to a decrease in the number and quality of eggs.
This awareness indicates that the patient is realistic about her chances of conceiving and is prepared to seek appropriate help if needed.
Choice D rationale:
While family history can play a role in infertility, it's not a guarantee that someone will experience the same issues as their relatives.
Each case is unique, and multiple factors can contribute to infertility, including genetics, lifestyle, medical conditions, and environmental factors.
It's important to undergo a thorough evaluation to determine the specific causes of infertility in each individual.
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