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?
Decrease the maintenance infusion rate of IV fluid.
Have protamine sulfate available at the bedside.
Reposition the client side-to-side each hour.
Monitor the client for hypertension
The Correct Answer is C
A. Decrease the maintenance infusion rate of IV fluid. Epidural anesthesia can cause hypotension, so IV fluids are often used to help maintain blood pressure. Reducing the fluid rate may increase the risk of hypotensive episodes.
B. Have protamine sulfate available at the bedside. Protamine sulfate is the antidote for heparin, not relevant to epidural anesthesia. It is not required in the management of epidural-related side effects.
C. Reposition the client side-to-side each hour. Frequent repositioning helps prevent pressure injuries, promotes fetal oxygenation, and encourages effective labor progression. It also aids in the distribution of the anesthetic agent.
D. Monitor the client for hypertension. Hypotension, not hypertension, is a common adverse effect of epidural anesthesia due to vasodilation and decreased peripheral resistance. Blood pressure should be monitored closely for drops.
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Related Questions
Correct Answer is D
Explanation
A. Naltrexone. This medication is used for opioid and alcohol use disorders. It helps reduce cravings and the pleasurable effects of those substances but is not indicated for smoking cessation.
B. Chlordiazepoxide. This is a benzodiazepine used to manage alcohol withdrawal symptoms, such as anxiety, tremors, and agitation. It is not appropriate for treating nicotine dependence.
C. Clonidine. Although primarily used for hypertension, clonidine has been used off-label to manage symptoms of opioid or nicotine withdrawal. However, it is not the first-line agent for smoking cessation.
D. Bupropion. This is an antidepressant also approved for smoking cessation. It helps reduce nicotine cravings and withdrawal symptoms and is often prescribed under the brand name Zyban for this purpose.
Correct Answer is C
Explanation
A. Refer the family to a chronic pain support group. While helpful, this is a later step in the care plan. The nurse must first assess the child's specific condition and patterns of pain.
B. Set up an appointment with the school nurse. This is a supportive measure but not the priority. The nurse must gather more information before involving school personnel.
C. Review the child's electronic pain diary. This is the first action because it allows the nurse to assess the frequency, triggers, severity, and duration of the migraines. Understanding the child's pain pattern is essential for effective treatment planning.
D. Request a change in medication from the provider. This may be necessary, but the nurse should first gather complete data on the child's symptoms and current response to treatment before suggesting changes to the medication regimen.
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