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 A
Explanation
Gestational diabetes mellitus (GDM) is a condition in which a pregnant woman develops high blood sugar levels during pregnancy. Complications of GDM can include macrosomia (a larger-than-average baby), polyhydramnios (an excessive amount of amniotic fluid), and preterm labor. One of the ways to monitor for these complications is through regular fundal height measurements. A fundal height measurement that is significantly larger than expected can indicate macrosomia or polyhydramnios, which can lead to complications during delivery.
Option B is incorrect because a fasting blood glucose of 90 mg/dL is within the normal range for a non-pregnant individual, and it is lower than the target range for a pregnant woman with GDM.
Option C is also incorrect because a fetal movement count of 12 in 1 hour is within the normal range.
Option D is incorrect because non-pitting pedal edema is a common finding in pregnancy and is not typically a cause for concern.
Correct Answer is ["C","D"]
Explanation
The nurse should plan to immunize the client with the following vaccines: Inactivated influenza: The Centers for Disease Control and Prevention (CDC) recommends that all pregnant women receive the influenza vaccine during any trimester of pregnancy, as pregnant women are at an increased risk of severe illness from the flu.
Diphtheria-acellular pertussis: The CDC recommends that pregnant women receive the Tdap vaccine (which includes protection against tetanus, diphtheria, and acellular pertussis) during each pregnancy, ideally between 27 and 36 weeks of gestation. This is to protect both the mother and the newborn from pertussis (whooping cough).
The following vaccines are not recommended:
Measles, mumps and rubella vaccine should not be given during pregnancy.
The HPV vaccine is not routinely recommended during pregnancy, and if the client becomes pregnant while receiving the HPV vaccine series, vaccination should be delayed until after the pregnancy.
The varicella vaccine (which protects against chickenpox) is not recommended during pregnancy, and if the client is not immune to chickenpox, the vaccine should be given after the pregnancy is over.
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