A nurse is caring for a client who is in labor, just received spinal anesthesia, and is experiencing hypotension. Which of the following actions should the nurse take?
Administer oxygen via nasal cannula at 2 L/min.
Place the client in a knee-chest position.
Assist the client to the bathroom.
Give 500 mL bolus of lactated Ringer's.
The Correct Answer is D
A. Administer oxygen via nasal cannula at 2 L/min: Oxygen may support maternal and fetal oxygenation, but it does not treat the underlying cause of hypotension following spinal anesthesia. It is a supportive measure, not the first-line intervention.
B. Place the client in a knee-chest position: This position is not recommended for treating hypotension due to spinal anesthesia. The priority is to improve perfusion through fluid resuscitation and positioning that enhances venous return, such as left lateral tilt.
C. Assist the client to the bathroom: Ambulation is unsafe for a client experiencing hypotension after spinal anesthesia and could worsen hypotension or cause falls. The client should remain supine or in a safe position until blood pressure is stabilized.
D. Give 500 mL bolus of lactated Ringer's: Administering a rapid IV fluid bolus is the first-line intervention for hypotension related to spinal anesthesia. It increases intravascular volume, improves venous return, and helps restore blood pressure to maintain maternal and fetal perfusion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. "I can change my cat's litter box every day.": Clients with leukemia are immunocompromised and at increased risk for infections such as toxoplasmosis from cat feces. They should avoid changing litter boxes or use protective measures like gloves and masks, so this statement indicates a misunderstanding of infection prevention.
B. "I will avoid blowing my nose when I feel congested.": Avoiding forceful nose blowing helps prevent mucosal trauma and bleeding, which is important for clients with leukemia who may have thrombocytopenia or fragile mucous membranes. This statement demonstrates an understanding of precautions to reduce injury and infection risk.
C. "I can continue gardening in my yard.": Gardening exposes the client to soilborne pathogens and bacteria, increasing the risk of infection. Clients with leukemia should avoid activities that involve soil contact unless using strict protective measures, so this statement indicates a lack of understanding.
D. "I will clean my toothbrush with an alcohol-based mouthwash.": Cleaning a toothbrush with mouthwash is not sufficient to prevent microbial contamination. Clients with leukemia should use a soft-bristled toothbrush and replace it regularly to minimize infection risk. This statement reflects incomplete understanding of oral care precautions.
Correct Answer is D
Explanation
A. Remove the surgical dressing and obtain a culture: Removing the dressing immediately is unnecessary for routine serosanguineous drainage, which is a normal finding in the early postoperative period. Cultures are only indicated if there are signs of infection such as purulent drainage, redness, or odor.
B. Irrigate the incision with saline: Irrigation is not required for normal serosanguineous drainage and may disrupt the healing process. It is reserved for wounds with debris, infection, or specific provider orders.
C. Clean the wound with hydrogen peroxide: Hydrogen peroxide can damage healthy tissue and delay healing. It is not indicated for routine postoperative care and should be avoided for normal drainage.
D. Mark the outline of the drainage: Marking the outline of the drainage allows the nurse to monitor for changes in amount and size over time. Tracking progression helps identify potential complications such as excessive bleeding or infection and supports timely interventions.
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