A nurse is caring for a client who is in labor and just received epidural anesthesia. The client's blood pressure is 90/50 mm Hg. Which of the following actions should the nurse take?
Turn the client onto their side.
Initiate an amnio-infusion for the client.
Administer naloxone to the client.
Monitor the client's blood pressure every 15 min.
The Correct Answer is A
Epidural anesthesia can cause hypotension in the mother, which can decrease blood flow to the fetus. Turning the client onto their side can help to improve blood flow to the fetus by reducing the pressure of the uterus on the vena cava and increasing venous return to the heart.
Option B is incorrect because an amnio-infusion is not indicated for hypotension related to epidural anesthesia.
Option C is also incorrect because naloxone is a medication used to reverse the effects of opioid medications and would not be appropriate for treating hypotension related to epidural anesthesia.
Option D is partially correct but does not address the immediate need to improve blood flow to the fetus. The nurse should monitor the client's blood pressure regularly but should also take immediate action to turn the client onto their side to improve blood flow.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Identification bands are an important safety measure to ensure that the newborn is properly identified and matched with the correct mother. Applying identification bands to the newborn and mother is a standard practice in all healthcare settings and is typically done immediately following delivery.
While obtaining the newborn's weight, administering IM vitamin K, and applying prophylactic eye ointment are also important interventions for a newborn, they should be done after the identification bands are applied. The order of priority for these interventions may vary depending on the healthcare facility's policies and procedures, but ensuring proper identification of the newborn is always the first step to ensure patient safety.
Correct Answer is B
Explanation
Constipation is a common problem for clients who have recently given birth, and suppositories are a common treatment option for constipation. However, suppositories are not appropriate for all clients. Certain conditions can be a contraindication to the use of suppositories, and the nurse should be aware of these conditions.
The nurse should identify that a third-degree perineal laceration is a contraindication to the use of a suppository, as it may cause further trauma to the already injured area. In this case, alternative treatments such as stool softeners or oral laxatives may be more appropriate for the client.
Option A is incorrect because although abdominal distention can be a sign of constipation, it is not a contraindication to the use of a suppository.
Option C is also incorrect because vaginal candidiasis is not a contraindication to the use of a suppository. In fact, suppositories are sometimes used to treat vaginal candidiasis.
Option D is also incorrect because afterpains are not a contraindication to the use of a suppository.
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