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 A
Explanation
A. Extension cords placed under area rugs: Placing extension cords under rugs creates a fire hazard and increases the risk of electrical shock. It can also cause trips and falls if the cords shift or become damaged, making it an unsafe environmental practice.
B. Refrigerator temperature is 3.3° C (38° F): This temperature is within the recommended safe range for storing perishable food, helping prevent bacterial growth. It does not pose a safety hazard.
C. Covers placed on unused electrical outlets: Outlet covers prevent children from inserting objects into outlets, reducing the risk of electrical shock. This is considered a positive safety measure, not a hazard.
D. A lamp plugged directly into a wall outlet: Plugging a lamp directly into a wall outlet is standard and safe when the outlet is not overloaded. It does not present a hazard under normal use.
Correct Answer is A
Explanation
A. Monitor the dorsalis pedis pulse every 15 min: Frequent assessment of peripheral pulses, such as the dorsalis pedis, is essential after a cardiac catheterization to detect early signs of arterial occlusion, bleeding, or compromised circulation. Monitoring every 15 minutes during the initial post-procedure period allows timely identification of complications.
B. Place the client in Fowler's position: After a femoral cardiac catheterization, the client is typically positioned supine with the affected leg straight to minimize bleeding and hematoma formation. Fowler’s position can increase stress on the groin puncture site and is not recommended immediately post-procedure.
C. Keep the client NPO for 24 hr: NPO status is not routinely required for 24 hours following cardiac catheterization. Clients may resume oral intake as tolerated once hemodynamically stable, unless contraindicated for other medical reasons.
D. Maintain strict bedrest for the first 12 hr: While bedrest is necessary immediately post-procedure, strict immobility is usually required for 2–6 hours, depending on the type of closure device or sheath used. Maintaining 12 hours of strict bedrest is longer than standard protocol and may unnecessarily increase discomfort and risk of complications like urinary retention.
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