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 B
Explanation
A. Bradypnea. Slow respiratory rate is not a typical sign of fluid overload. In fact, fluid volume excess may lead to tachypnea or dyspnea as fluid accumulates in the lungs and impairs gas exchange.
B. Distended neck veins. Jugular vein distention is a classic sign of fluid volume overload. It reflects increased central venous pressure and is commonly seen in clients receiving excessive IV fluids or those with heart failure.
C. Weight loss. IV fluid therapy is intended to increase intravascular volume, and adverse effects are usually related to fluid retention, not loss. Weight gain, not weight loss, would indicate fluid overload.
D. Bradycardia. An increased, not decreased, heart rate (tachycardia) is typically seen with fluid volume excess or in response to fluid shifts. Bradycardia is not a common adverse effect of IV fluid therapy.
Correct Answer is C
Explanation
A. "You should make sure your partner takes the prescribed medication." While medication adherence is important, this response shifts the focus to advice-giving rather than exploring the partner’s emotions or current experience, which limits therapeutic communication.
B. "You did the right thing by bringing your partner in for treatment." Although supportive, this statement closes off the conversation and doesn’t invite the partner to share more about their feelings or the situation at home.
C. "Can you talk about what was happening with your partner at home?" This open-ended, therapeutic response encourages the partner to express their thoughts and emotions, facilitating a better understanding of the client’s condition and the impact it has had on the family.
D. "Why do you think your partner's symptoms are progressing so quickly?" Asking “why” can feel accusatory or put the partner on the defensive. It may also imply blame, which is not helpful in building trust or gathering therapeutic insight.
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