A nurse is caring for a client who is experiencing an amniotic fluid embolism during labor.
Which of the following actions should the nurse take?
Plan to administer ephedrine IV.
Assist the client to empty their bladder.
Assess for the presence of clonus.
Prepare to initiate cardiopulmonary resuscitation.
The Correct Answer is D
Choice A rationale:
Administering ephedrine IV is not the appropriate action for a client experiencing an amniotic fluid embolism during labor. Ephedrine is typically used to treat hypotension during spinal anesthesia, not amniotic fluid embolism.
Choice B rationale:
Assisting the client to empty their bladder is not the appropriate action for a client experiencing an amniotic fluid embolism during labor. While bladder care is important, it is not the priority in this situation.
Choice C rationale:
Assessing for the presence of clonus is not the appropriate action for a client experiencing an amniotic fluid embolism during labor. Clonus is typically assessed in clients with preeclampsia or eclampsia, not amniotic fluid embolism.
Choice D rationale:
Preparing to initiate cardiopulmonary resuscitation is the appropriate action for a client experiencing an amniotic fluid embolism during labor. Amniotic fluid embolism can lead to cardiovascular collapse, therefore, immediate resuscitation measures should be prepared15.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Replacing the infant’s identification band after his name has been recorded is not a recommended practice for newborn identification.
Choice B rationale:
Checking the newborn’s identification using the crib card is not a recommended practice for newborn identification.
Choice C rationale:
Obtaining an imprint of the infant’s feet prior to taking him to the nursery is a reliable method of identification of the newborn.
Choice D rationale:
Requiring visitors to wear an identification band is not a recommended practice for newborn identification.
Correct Answer is A
Explanation
Choice A rationale:
Hypotension is a common adverse effect of epidural analgesia due to the blockage of sympathetic nerve fibers, which can lead to vasodilation and decreased cardiac output.
Choice B rationale:
Polyuria is not typically associated with epidural analgesia. It could be related to other factors such as fluid administration or underlying medical conditions.
Choice C rationale:
A fetal heart rate of 152/min is within the normal range (110-160 beats/min) and is not an adverse effect of epidural analgesia.
Choice D rationale:
A maternal temperature of 37.4° C (99.4° F) is within the normal range (36.1° C to 37.2° C or 97° F to 99° F) and is not an adverse effect of epidural analgesia.
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