A nurse is caring for a client who is in labor and has an epidural anesthesia block. The client's blood pressure is 80/40 mm Hg, and the fetal heart rate is 140/min. Which of the following is the priority nursing action?
Elevate the client's legs.
Place the client in a lateral position.
Monitor vital signs every 5 minutes.
Notify the provider.
The Correct Answer is B
Choice A: Elevating the client's legs is a measure to increase blood flow to the brain in cases of orthostatic hypotension but may not be sufficient to improve fetal oxygenation in this situation. The lateral position is preferred as it improves uterine perfusion.
Choice B: The client's blood pressure of 80/40 mm Hg indicates hypotension, which can be a common side effect of epidural anesthesia. The priority nursing action is to place the client in a lateral (sidelying) position to improve blood flow to vital organs, including the uterus and placenta, and prevent further compromise of fetal oxygenation.
Choice C: Monitoring vital signs every 5 minutes is an important nursing action, but the priority in this situation is to address the hypotension and improve maternal and fetal wellbeing first.
Choice D: Notifying the provider is an important step, but it should not be the first action. Immediate intervention to address the hypotension is required to improve fetal oxygenation.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A) "It is used to treat genital herpes simplex virus.": This statement is incorrect. Dinoprostone (Cervidil) gel is not used to treat genital herpes simplex virus; it is used in obstetrics to ripen the cervix and prepare it for labor induction.
B) "This medicine causes relaxation of the uterine muscles.": While dinoprostone is a prostaglandin that can induce uterine contractions, its primary use in this context is cervical ripening, not uterine muscle relaxation.
C) "This medication is used to treat preeclampsia.": Dinoprostone is not used to treat preeclampsia. It is used for cervical ripening and labor induction in appropriate situations.
D) "This medication is used to ripen, or soften, the cervix.": This is the correct answer. Dinoprostone (Cervidil) gel is used to ripen the cervix, making it more favorable for labor induction, especially in cases where the cervix is not yet fully dilated or effaced.
Correct Answer is D
Explanation
Choice A: "I should not drink alcoholic beverages during my pregnancy." Correct, as alcohol consumption during pregnancy can lead to fetal alcohol spectrum disorders and other adverse outcomes.
Choice B: "I should drink about 2 liters of fluid each day." Correct, as adequate hydration is essential during pregnancy.
Choice C: "I can have a moderate amount of caffeine daily." Correct, as moderate caffeine consumption is generally considered safe during pregnancy (around 200300 mg per day).
Choice D: During pregnancy, certain fish types can be high in mercury, which can be harmful to the developing fetus. Fish with high mercury levels should be limited or avoided during pregnancy.
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