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.
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Related Questions
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.
Correct Answer is A
Explanation
It is important to ensure the safety of the newborn, and in this situation, the adolescent mother is putting the newborn at risk by leaving him unattended while feeding. Offering to take the newborn to the nursery allows him to finish feeding in a safe environment while also allowing the nurse to assess his feeding and ensure he is receiving adequate nutrition. It is important to provide education to the mother on safe feeding practices, but at this moment, ensuring the safety of the newborn is the priority.
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