A nurse is caring for a client who is hypotensive following the administration of epidural anesthesia. Which of the following actions should the nurse take?
Massage the client's fundus
Turn the client to a side-lying position
Apply oxygen at 2 L/min via nasal cannula
Assist the client to empty their bladder.
The Correct Answer is B
Rationale:
A. Massaging the client's fundus is not indicated for hypotension following epidural anesthesia.
Fundal massage is typically performed to prevent or manage uterine atony and postpartum hemorrhage.
B. Turning the client to a side-lying position is a recommended intervention for hypotension following epidural anesthesia. This position helps improve venous return to the heart and can help alleviate hypotension by reducing aortocaval compression.
C. Applying oxygen via nasal cannula may be indicated if the client is experiencing respiratory distress, but it is not the primary intervention for hypotension.
D. Assisting the client to empty their bladder may be appropriate to relieve urinary retention but is not the priority intervention for hypotension.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
- A: Subconjunctival hemorrhage is generally a benign condition in newborns, often caused by the pressure changes during birth and does not typically require intervention.
- B: Rust-stained urine could indicate urate crystals, which are common in newborns and not usually a concern unless accompanied by other symptoms.
- C: Transient circumoral cyanosis can occur normally in newborns due to immature circulation but should resolve quickly; persistent or severe cases may require further evaluation.
- D: Single palmar creases may be associated with certain genetic conditions and warrant further investigation and reporting to a healthcare provider.
Correct Answer is C
Explanation
Rationale:
A. Ectopic pregnancy occurs when a fertilized egg implants outside the uterus, typically in the fallopian tube. This scenario does not match the clinical presentation described.
B. Incompetent cervix is characterized by painless cervical dilation in the second trimester and is not relevant to the clinical situation described.
C. Postpartum hemorrhage is a risk when a woman is in advanced labor with significant cervical dilation. The nurse should be vigilant for signs of hemorrhage during labor and after delivery.
D. Hyperemesis gravidarum is severe nausea and vomiting during pregnancy and is not directly related to the client's current labor status.
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