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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Correct Answer is C
Explanation
Choice A: While an upright position is generally beneficial during labor to improve uterine contractions and fetal positioning, it is not the priority in this situation of hypotension.
Choice B: Preparing for a cesarean birth is not indicated solely based on the blood pressure reading. Cesarean birth should be considered based on the overall assessment and clinical condition of the client and baby.
Choice C: The client's blood pressure reading of 82/52 mm Hg indicates hypotension. In this situation, the nurse should assist the client in turning onto her side to relieve pressure on the vena cava and improve blood flow to the placenta and the baby. Lying supine can compress the vena cava, leading to decreased venous return and reduced cardiac output, which may negatively affect fetal oxygenation and maternal wellbeing.
Choice D: Preparing for an immediate vaginal delivery is not the priority at this moment. The nurse should first address the hypotension and improve maternal blood flow before proceeding with delivery.
Correct Answer is B
Explanation
Choice A: Engagement of the presenting part occurs when the baby's head descends into the pelvis. While it is a sign of labor progression, it can also happen weeks before labor begins.
Choice B: Progressive changes in the effacement (thinning) and dilation (opening) of the cervix are the most reliable signs of true labor. As the cervix changes, it indicates that labor is actively occurring.
Choice C: Rupture of the membranes (water breaking) is another sign of labor, but it can happen before or during labor. It may not be the most reliable sign by itself.
Choice D: Regular and frequent contractions are essential for labor to progress, but an irregular pattern of contractions may still be associated with false labor or early labor.
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