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?

A. Administering broad-spectrum antibiotics is important because a leaking myelomeningocele increases the newborn’s risk for infection, including meningitis. Early prophylactic antibiotic therapy helps prevent serious complications.

B. Cleansing the site with povidone-iodine is not recommended because antiseptics can irritate neural tissue and worsen leakage. The sac should be kept sterile and moist using a saline-soaked sterile dressing instead.

C. Monitoring rectal temperature is contraindicated because rectal manipulation can risk trauma to the myelomeningocele sac. Noninvasive temperature monitoring, such as axillary measurement, is safer.

D. Surgical closure should be performed as soon as possible, ideally within 24–48 hours after birth, rather than waiting 72 hours, to reduce the risk of infection and further neurologic damage.

Rationale:

A. Applying an ice pack to the incision site is not indicated for addressing vaginal bleeding after cesarean birth and may not effectively address the underlying cause.

B. Replacing the surgical dressing is not the first action to take when assessing vaginal bleeding after cesarean birth. The priority is to evaluate the client's condition and identify the cause of the bleeding.

C. Evaluating urinary output is important to assess for urinary retention, which can contribute to uterine atony and postpartum bleeding. A full bladder can interfere with uterine contraction and lead to increased bleeding.

D. Administering a lactated Ringer's IV bolus may be indicated if the client is hypovolemic due to excessive bleeding, but it is not the first action to take. Assessing urinary output and addressing potential causes of bleeding take precedence.