A nurse in a provider's office is caring for a client.

Exhibits

What actions should the nurse take?

Select all that apply.

A. This is a good practice in medication administration, especially for high-risk medications like antibiotics. Having another nurse verify the medication can help prevent errors, ensuring that the right drug, dose, and administration route are followed. However, this action is not specific to the steps needed to administer the IV bolus.

B. Hanging the secondary infusion higher allows gravity to assist in the flow of the antibiotic solution into the IV line while ensuring that the primary infusion continues to flow simultaneously. This is a standard practice for administering intermittent IV medications.

C. It is not necessary to disconnect the primary IV infusion completely unless it is specifically indicated by the healthcare provider or hospital protocol. Interrupting the continuous infusion briefly to administer the antibiotic bolus and then resuming the primary infusion afterward is a common practice. This approach maintains continuous hydration and avoids unnecessary manipulation of the IV line.

D. Flushing with sterile water or saline before connecting the antibiotic bolus can help maintain the integrity of the IV line and prevent contamination. However, the type of flush solution (sterile water vs. saline) may depend on hospital policy or specific clinical circumstances.

A. Hypotension (low blood pressure) is a common side effect of epidural anesthesia due to the vasodilatory effects of the local anesthetic. It can lead to decreased perfusion to vital organs and compromise fetal oxygenation. Hypotension is a critical finding because it can affect both the mother and the fetus. In severe cases, hypotension can lead to maternal dizziness, nausea, vomiting, decreased

uteroplacental perfusion, and fetal distress. Prompt intervention such as administering IV fluids and positioning the client to improve venous return is necessary to stabilize blood pressure and prevent adverse outcomes.

B. Leg weakness can occur as a result of epidural anesthesia affecting the lower extremities. It is typically a transient and expected side effect. While leg weakness can impact the client's comfort and mobility, it is not as immediately concerning as hypotension in terms of potential complications for both the mother and the fetus.

C. Urinary retention is a common side effect of epidural anesthesia but is generally managed by monitoring and, if necessary, catheterization. While it requires attention, it is not typically considered a higher priority compared to hypotension.

D. An elevated temperature can indicate infection or a systemic inflammatory response, which may require investigation and treatment. While an elevated temperature is concerning and warrants further assessment to determine its cause, it is not typically the highest priority compared to managing hypotension, which can have more immediate and significant effects on both the mother and the fetus.