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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Urinary output 120 mL/4 hr. This is on the lower end of normal but not critical. It should be monitored, especially in clients on opioids, but does not require immediate reporting ahead of more life-threatening findings.
B. Pupil diameter 6 mm. Dilated pupils may suggest other issues such as anxiety, medication effects, or pain, but are not a common concern with morphine, which usually causes miosis (pupil constriction). Still, this is not the most urgent concern.
C. Bowel movement 5 days ago. Constipation is a common side effect of opioids, including morphine, and should be addressed with stool softeners or laxatives. However, it is not an emergency.
D. Blood pressure 80/40 mm Hg. This indicates hypotension, a potentially life-threatening side effect of IV morphine, especially if it results in decreased perfusion or shock. It requires immediate intervention and provider notification.
Correct Answer is B
Explanation
A. Irrigate the wound using a 10-mL syringe. A 10-mL syringe does not provide adequate pressure for effective irrigation. Typically, a 30- to 60-mL syringe with an 18-gauge catheter is used to deliver appropriate pressure (between 4–15 psi) to clean wounds effectively.
B. Irrigate the wound with a low-pressure flow of solution. This is correct. A low-pressure irrigation system helps gently remove debris and bacteria without damaging healthy tissue. It also minimizes the risk of forcing contaminants deeper into the wound bed.
C. Cleanse the insertion site of the drain using a circular motion toward the center. The site should be cleansed from the center outward, not toward the center, to prevent dragging contaminants into the insertion site and reduce infection risk.
D. Cleanse the wound starting at the bottom and moving upward. Wound cleaning should occur from the least contaminated (top) to the most contaminated (bottom) area to avoid transferring microorganisms from dirtier areas to cleaner areas, thereby minimizing the risk of infection.
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