A nurse is caring for a client who is in active labor and is scheduled to receive epidural anesthesia.
Which of the following actions should the nurse take?

B. "You may experience a headache after receiving this medication."

• Some tocolytic medications can cause headaches as a side effect.

C. "It is common for this medication to make you feel jittery."

• Tocolytic medications, such as terbutaline, can cause nervousness or jitteriness.

D. "This medication should decrease your contractions."

• The primary purpose of tocolytic medication is to decrease uterine contractions and delay preterm labor.

E. "I'll check your reflexes frequently while you are receiving this medication."

• Some tocolytic medications, like magnesium sulfate, require monitoring of deep tendon reflexes to assess for potential toxicity.

F. "This medication can make your heart beat faster."

• Tocolytic medications, such as terbutaline, can increase heart rate.

These statements provide the client with a comprehensive understanding of the purpose of the medication and its potential side effects.

The incorrect statements are:

• A. "I will inject this medication under your skin.": Tocolytic medications are typically administered orally, intravenously, or intramuscularly, not subcutaneously.
• G. "This medication can increase your blood pressure.": Some tocolytic medications, like magnesium sulfate, can actually lower blood pressure rather than increase it.

The correct answer is Choice C

Choice A rationale: Clinical manifestations of hypovolemic shock typically begin when approximately 15% to 30% of total blood volume is lost. In pregnancy, total blood volume increases by about 30% to 50%, so signs may be masked initially. However, waiting until 20% loss to expect symptoms is misleading. Tachycardia, pallor, and hypotension may appear earlier. Therefore, this statement underestimates the sensitivity of maternal physiology to blood loss and is not scientifically accurate.

Choice B rationale: Hemorrhagic shock leads to tissue hypoperfusion and anaerobic metabolism, resulting in lactic acid accumulation and metabolic acidosis. This causes a decrease in serum pH, not an increase. Normal serum pH ranges from 7.35 to 7.45. In shock states, pH often drops below 7.35, indicating acidosis. An increase in pH would suggest alkalosis, which is not consistent with the pathophysiology of hemorrhagic shock. Thus, this statement contradicts basic acid-base science.

Choice C rationale: Urine output is a direct and sensitive indicator of renal perfusion and overall organ perfusion. The kidneys require adequate blood flow to maintain glomerular filtration. In shock, decreased cardiac output reduces renal perfusion, leading to oliguria. Normal urine output is ≥30 mL/hr. Persistent reduction below this threshold reflects compromised perfusion. Unlike blood pressure or heart rate, urine output is less influenced by compensatory mechanisms, making it a reliable marker of end-organ function.

Choice D rationale: Fluid resuscitation in hemorrhagic shock typically involves a 3:1 ratio of isotonic crystalloid (e.g., lactated Ringer’s) to blood loss volume. This accounts for the distribution of fluid into the interstitial and intracellular compartments. Administering only 1 mL of fluid per 1 mL of blood loss is insufficient to restore intravascular volume. The 3:1 replacement rule is based on fluid dynamics and vascular compartmentalization. Therefore, this statement misrepresents standard resuscitation protocols.