A nurse is caring for a client who is in labor and just received epidural anaesthesia. 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 amnioinfusion for the client
Administer naloxone to the client
Monitor the client’s blood pressure every 15 min
The Correct Answer is A
A common side effect of epidural anaesthesia is a drop in blood pressure. Turning the client onto their side can help improve blood flow to the uterus and baby and may help raise the mother’s blood pressure.
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Related Questions
Correct Answer is D
Explanation
After giving birth, a woman's body undergoes many changes, including changes in the size and shape of the vagina. It is essential to have the correct size of diaphragm to ensure its effectiveness.
Therefore, the nurse should instruct the client to have a provider refit her for a new diaphragm.
Option a is incorrect because the diaphragm should be cleaned with warm water and mild soap, not an oil- based vaginal lubricant.
Option b is incorrect because the diaphragm should be removed no sooner than 6 hours after intercourse but should not be left in place for more than 24 hours.
Option c is incorrect because oil-based vaginal lubricants can damage latex diaphragms, reducing their effectiveness as a contraceptive method. Water-based lubricants should be used instead.
Correct Answer is B
Explanation
Rationale for A: Monitoring the rectal temperature is important, but every 4 hours may not be frequent enough to assess for signs of infection or other complications in a newborn with myelomeningocele.
Rationale for B: Administering broad-spectrum antibiotics is crucial to prevent infection, especially in cases of myelomeningocele where the protective covering of the spinal cord is compromised.
Rationale for C: Cleansing the site with povidone-iodine is not recommended as it can be irritating and potentially harmful to the delicate tissue surrounding the defect.
Rationale for D: Surgical closure is typically performed as soon as possible after birth, often within 24 hours, rather than delaying it for 72 hours.
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