A nurse is caring for a client who is in active labor.

Exhibits

The nurse is caring for a client following the insertion of an epidural. For each nursing intervention, click to specify if the intervention is essential or contraindicated for the client.

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.

A. Simply documenting the client's lack of understanding does not address their immediate need for clarification. The nurse must take action.
B. The provider is responsible for obtaining informed consent and ensuring the client understands the procedure. The nurse should notify the provider so they can provide the necessary explanation.
C. Discussing other treatment options is beyond the nurse’s scope of practice. Only the provider should discuss alternative treatments.
D. The nurse can reinforce teaching but cannot provide new information about the surgery. Since the client is unsure about the procedure, the provider must explain it.