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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.

A.

Decrease the IV flow rate.

B.

Monitor fetal heart rate

C.

Administer ampicillin IV

D.

Place client in left lateral position.

E.

Request a prescription for ephedrine.

Answer and Explanation

The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"}}

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.


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Related Questions

Correct Answer is D

Explanation

A. A client who has heart failure and received furosemide IV 8 hr ago:
Clients with heart failure require ongoing monitoring for fluid balance, electrolyte levels, and signs of worsening symptoms. IV furosemide indicates active treatment, so this client is not stable for discharge.

B. A client who was admitted 24 hr ago with chest pain:
A client with recent chest pain requires further evaluation for acute coronary syndrome (ACS). Even if pain has resolved, monitoring for cardiac events is essential. This client is not stable for discharge.

C. A client who had a seizure 48 hr ago and is on seizure precautions:
Recent seizures require continued monitoring to assess for recurrence, medication adjustments, and safety precautions. This client is not stable for discharge.

D. A client who is scheduled to have a colonoscopy in 12 hr:
A colonoscopy is an elective procedure and does not require hospitalization. This client is stable and can be discharged to free up resources for mass casualty victims.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"B"}}

Explanation

Findings Consistent with Chorioamnionitis:

  • Purulent amniotic fluid
  • Fever

Findings Consistent with Preeclampsia:

  • Elevated uric acid level
  • Decreased platelet count
  • Blurred vision

Rationale:

  • Purulent amniotic fluid (Chorioamnionitis): Chorioamnionitis is an intra-amniotic infection, often leading to foul-smelling, purulent, or discolored amniotic fluid.
  • Fever (Chorioamnionitis): Maternal fever is a hallmark sign of chorioamnionitis, indicating infection.
  • Elevated uric acid level (Preeclampsia): Uric acid elevation is associated with endothelial dysfunction and reduced renal clearance seen in preeclampsia.
  • Decreased platelet count (Preeclampsia): Thrombocytopenia can occur due to platelet consumption in severe preeclampsia or HELLP syndrome.
  • Blurred vision (Preeclampsia): Visual disturbances occur due to cerebral edema and vasospasms, common in preeclampsia.

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