A nurse is caring for a client who is in labor and has received an epidural. Which of the following actions should the nurse take?
Monitor the client for hypertension.
Decrease the maintenance infusion rate of IV fluid.
Have protamine sulfate available at the bedside.
Reposition the client side-to-side each hour.
The Correct Answer is D
A. Monitor the client for hypertension: Epidural anesthesia commonly causes hypotension rather than hypertension due to sympathetic blockade and vasodilation. Continuous monitoring is essential, but the nurse focuses on identifying and managing hypotension.
B. Decrease the maintenance infusion rate of IV fluid: IV fluids are often administered before and during epidural placement to prevent hypotension. Reducing the infusion rate could worsen hypotension and compromise maternal and fetal perfusion.
C. Have protamine sulfate available at the bedside: Protamine sulfate is used to reverse heparin anticoagulation. It is not relevant to epidural administration and does not address the common risks associated with epidural anesthesia.
D. Reposition the client side-to-side each hour: Repositioning the client promotes maternal comfort, prevents pressure injury, and improves uteroplacental perfusion. Side-to-side positioning is recommended to avoid aortocaval compression and maintain adequate fetal oxygenation during labor.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","E","F","G"]
Explanation
Rationale for correct choices
• Client reports lower back pain as 0 on a scale from 0 to 10: Resolution of back pain suggests that uterine contractions and associated discomfort have decreased, indicating reduced preterm labor activity and improved comfort. Pain control and labor suppression interventions appear effective.
• No further reports of burning with urination: The absence of dysuria indicates that a possible urinary tract infection is improving, either spontaneously or following interventions such as increased hydration or antibiotic therapy. Symptom resolution reflects clinical improvement.
• No uterine contractions noted: The absence of contractions indicates that preterm labor activity has decreased. This reflects effective management and a positive trend in preventing progression to preterm birth.
• Temperature 37.1° C (98.7° F): A normalized temperature reflects a reduction in maternal infection or inflammatory response. This indicates that the client’s fever is resolving, decreasing risk for maternal and fetal complications.
• No reports of vaginal discharge: The absence of abnormal vaginal discharge suggests that cervical or infection-related changes are resolving, reflecting decreased risk of preterm labor progression
• WBC count 12,000/mm³: The white blood cell count has decreased from the initial 16,000/mm³, showing a positive response to antibiotic therapy. A decrease from the previous elevated WBC count indicates that infection or inflammation is resolving, demonstrating laboratory improvement and decreased maternal risk.
Rationale for incorrect choices
• FHR baseline 138/min, minimal variability: A baseline fetal heart rate within normal limits is reassuring, but minimal variability persists, indicating continued need for monitoring. This alone does not indicate full clinical improvement.
Correct Answer is B
Explanation
A. Aspirin 1 tablet daily: This prescription is incomplete because it does not specify the dosage strength (e.g., 81 mg or 325 mg). Without the strength, safe administration cannot be ensured.
B. Metoprolol 5 mg IV now: This prescription is complete because it includes the medication name, exact dosage, route of administration, and timing (“now”), providing all necessary information for safe administration.
C. Nitroglycerin transdermal patch: This prescription is incomplete as it does not specify the dosage strength (e.g., 0.1 mg/hr), location of application, or timing, which are necessary for safe and effective use.
D. Furosemide 20 mg BID: This prescription is incomplete because it does not specify the route of administration (oral or IV), which is essential for safe administration and proper monitoring of effects.
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