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 C
Explanation
Absent deep tendon reflexes are a sign of magnesium toxicity, which can occur with high levels of magnesium in the bloodstream. This can be a serious complication that requires immediate atention from the provider.
Option A, a decrease in frequency of contractions, is actually a desired effect of magnesium sulfate in the management of preterm labor. It is not a cause for concern.
Option B, a blood pressure reading of 150/100 mm Hg, is high, but it is not necessarily related to the administration of magnesium sulfate. However, it should still be reported to the provider for appropriate management.
Option D, a urinary output of 35 mL/hr, is below the normal range but it may still be within an acceptable range for a client receiving magnesium sulfate. The provider should be notified if urinary output continues to decrease or if it falls below a certain threshold.
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