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 C
Explanation
A. Using a communication board is appropriate for clients with speech or language impairments, not visual impairment.
B. Collaborating with a speech therapist is indicated for speech or communication disorders, not vision loss.
C. Using indirect lighting in the room is correct because it reduces glare and enhances visibility for clients with visual impairment, improving safety and comfort.
D. Speaking in a loud tone of voice is unnecessary unless the client also has a hearing impairment; visual impairment does not affect hearing.
Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"}}
Explanation
- Prolonged rupture of membranes: Rupture of membranes lasting longer than 18 hours increases the risk of ascending bacterial infection, leading to conditions such as endometritis. This is a known risk factor for postpartum infection, especially following cesarean delivery.
- Polyhydramnios: An excessive amount of amniotic fluid overdistends the uterus, which can impair its ability to contract effectively postpartum, making uterine atony more likely. Atony can lead to increased bleeding or retained lochia.
- Prenatal anemia: While not directly causing infection, anemia impairs immune function, increasing a person's susceptibility to postpartum infections. It can also worsen recovery from infections or surgical wounds.
- High parity: Multiple prior pregnancies stretch the uterus over time, reducing myometrial tone, which predisposes to uterine atony. This makes it harder for the uterus to contract adequately after delivery, increasing the risk for hemorrhage or subinvolution.
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