A nurse is caring for a patient who is in labor and has an epidural anesthesia block. The patient’s blood pressure is 80/40 mm Hg and the fetal heart rate is 140/min.
Which of the following is the priority nursing action?

Choice A rationale

Eyelid swelling is not a common side effect of sumatriptan. If a patient experiences this side effect, they should report it to their healthcare provider.

Choice B rationale

If the headache persists after taking sumatriptan, the patient can repeat the dose in 1 hour. This is a standard instruction for the use of sumatriptan in the treatment of migraine headaches.

Choice C rationale

Sumatriptan is not typically taken daily to prevent headaches. It is used to treat migraines once they have started.

Choice D rationale

Sumatriptan tablets should be swallowed whole, not chewed. Chewing the tablet could result in too much of the drug being released at once.

Choice A rationale

Performing passive range of motion exercises on the right leg in Buck’s traction may not be appropriate. These exercises involve moving the joint without the patient’s muscles doing the work, which could disrupt the traction.

Choice B rationale

Isometric exercises involve contracting the muscles without moving the joints. While these exercises can be beneficial for maintaining muscle strength, they may not promote mobility.

Choice C rationale

Performing active range-of-motion exercises on the left leg can help promote mobility. These exercises involve the patient moving the joint through its full range of motion, which can help maintain joint flexibility and muscle strength.

Choice D rationale

Log rolling the patient every 2 hours may not be appropriate for a patient in Buck’s traction. This technique involves turning the patient as a unit to prevent twisting and protect the spine, which could disrupt the traction.