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?

Monitor vital signs every 5 min.

Place the patient in a lateral position.

Elevate the patient’s legs.

Notify the provider.

Answer and Explanation

The Correct Answer is B

The priority nursing action for a patient in labor with an epidural anesthesia block and a blood pressure of 80/40 mm Hg is to place the patient in a lateral position. This can help improve maternal blood flow and fetal oxygenation.

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Correct Answer is D

Explanation

Choice A rationale

Constipation is a potential side effect of aripiprazole, but it is not typically a serious concern that would require notifying the provider.

Choice B rationale

Weight gain of 5 lb in 1 month could be a side effect of aripiprazole, but it is not typically a serious concern that would require notifying the provider.

Choice C rationale

Insomnia is a potential side effect of aripiprazole, but it is not typically a serious concern that would require notifying the provider.

Choice D rationale

Muscle stiffness could be a sign of a serious side effect of aripiprazole known as extrapyramidal symptoms. This could include conditions such as dystonia, akathisia, and Parkinsonism. If a patient experiences muscle stiffness while taking aripiprazole, the healthcare provider should be notified.

A. Assess orthostatic blood pressure. B. Administer pain medication. C. Explain the procedure for an upper gastrointestinal series. D. Test the patient’s emesis for blood.

Correct Answer is A

Explanation

The first action the nurse should take when caring for a patient with gastrointestinal bleeding is to assess orthostatic blood pressure. This can help determine the extent of the patient’s blood loss and whether they are experiencing hypovolemia.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a patient who has schizophrenia and is taking aripiprazole. The nurse should notify the provider of which of the following findings?

Correct Answer is D

Explanation

A nurse is caring for a patient who has gastrointestinal bleeding. Which of the following actions should the nurse take first?

Correct Answer is A

Explanation

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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?