A nurse in an antepartum unit is caring for a client.
 

Exhibits

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Nurses' Notes

2230:

Contractions occurring every 2.5 to 3 minutes, lasting 60 to 70 seconds. Epidural placed by anesthesiologist. Client rates pain with contractions as a 3 on a scale of 0 to 10. FHR 150/min with moderate variability. Accelerations present, no decelerations noted.

Vital Signs

2230:

Temperature 38° C (100.4° F)

Heart rate 88/min

Respiratory rate 16/min

Blood pressure 122/80 mm Hg

Oxygen saturation 98% on room air

The nurse should prepare to administer naloxone and oxygen by face mask 10 L/min.

Rationale:

• Naloxone is used to reverse opioid-induced respiratory depression, which is a potential risk during moderate sedation.
• Oxygen by face mask 10 L/min is necessary to maintain adequate oxygenation during and after sedation, as respiratory depression can occur.

• Acetaminophen is not used for immediate management of sedation-related complications.
• An additional dose of fentanyl or propofol would deepen sedation, not manage its complications.
• Propranolol is a beta-blocker that is not indicated in this situation.

Essential Interventions:

• Monitor fetal heart rate
• Administer ampicillin IV
• Place client in left lateral position
• Request a prescription for ephedrine

Contraindicated Intervention:

• Decrease the IV flow rate

Rationale:

• Monitor fetal heart rate (Essential): Epidural anesthesia can cause maternal hypotension, leading to decreased uteroplacental perfusion. Continuous fetal heart rate monitoring ensures the fetus is tolerating labor well.
• Administer ampicillin IV (Essential): The client tested positive for Group B Streptococcus (GBS) at 37 weeks, requiring prophylactic IV antibiotic administration during labor to prevent neonatal infection.
• Place client in left lateral position (Essential): This position improves venous return, enhances placental perfusion, and prevents hypotension caused by epidural anesthesia.
• Request a prescription for ephedrine (Essential): Epidural anesthesia can cause maternal hypotension, and ephedrine is a vasopressor that can help restore blood pressure if needed.
• Decrease the IV flow rate (Contraindicated): IV fluids should be maintained or increased to prevent hypotension, a common side effect of epidural anesthesia. Reducing the IV rate could exacerbate hypotension and fetal distress.