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

Answer and Explanation

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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Correct Answer is D

Explanation

A. "You should take a second dose if there is no relief within fifteen minutes after the initial dose." The second dose of sumatriptan should not be taken sooner than 2 hours after the first dose if there is no relief or if the migraine returns. Taking it too soon increases the risk of adverse effects.
B. "You may experience low blood pressure while taking this medication." Sumatriptan more commonly causes hypertension, not hypotension. It can cause vasoconstriction, which may elevate blood pressure and poses risks, especially in clients with cardiovascular disease.
C. "You should have complete relief in six hours after taking this medication." Relief from sumatriptan is often experienced within 1–2 hours after administration. While not all clients achieve complete relief, the medication acts quickly, and six hours is not the expected timeframe.
D. “You may experience muscle cramps as a potential adverse effect of the medication." Muscle cramps or tightness in the chest, neck, or limbs can occur due to vasoconstriction caused by sumatriptan. This is a known side effect and should be reported if severe or persistent.

A. "Remain on bed rest for 24 hours following the procedure." B. "Participate in range-of-motion exercises." C. "Place a pillow under your knees while in bed." D. "Use an incentive spirometer every 4 hours."

Correct Answer is B

Explanation

A. "Remain on bed rest for 24 hours following the procedure." Prolonged bed rest increases the risk of venous thromboembolism (VTE) and pulmonary complications. Early ambulation or movement is encouraged to promote circulation and prevent complications.
B. "Participate in range-of-motion exercises." Range-of-motion (ROM) exercises help stimulate venous return, improve circulation, and prevent blood stasis, which lowers the risk of postoperative blood clots and muscle stiffness.
C. "Place a pillow under your knees while in bed." Placing a pillow under the knees can impair circulation and increase the risk of venous stasis and thrombus formation. It is not recommended for circulation promotion.
D. "Use an incentive spirometer every 4 hours." While this instruction helps prevent respiratory complications, it is not a direct intervention for improving circulatory function. It's primarily used to promote lung expansion postoperatively.

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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?

Nursing Test Bank

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