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. "How are things going at your job?" This response redirects the conversation rather than addressing the client's emotional state.
B. "Why do you think this is happening to you?" This question may come across as challenging or blaming, which is not therapeutic.
C. "You must be feeling very frightened right now." This response validates the client's emotions, showing empathy and encouraging further expression of feelings.
D. "Maybe you should think more positively." This dismisses the client's distress and does not provide therapeutic support.

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.