A nurse is planning care for a client who is in labor and is requesting epidural anesthesia for pain control. Which of the following actions should the nurse include in the plan of care?
Place the client in a supine position for 30 min following the first dose of anesthetic solution.
Administer 1.000 mL of dextrose 5% in water prior to the first dose of anesthetic solution.
Monitor the client's blood pressure every minute following the first dose of anesthetic solution.
Ensure the client has been NPO 4 hr prior to the treatment of the epidural and the first dose of anesthetic solution.
The Correct Answer is C
Choice A Reason:
Placing the client in a supine position for 30 minutes following the first dose of anesthetic solution is not a standard recommendation. The positioning during epidural placement is typically a seated or side-lying position.
Choice B Reason:
Administering 1,000 mL of dextrose 5% in water prior to the first dose of anesthetic solution is not a standard practice for epidural anesthesi
A. Fluids may be administered, but the type and volume depend on the patient's individual needs and the healthcare provider's orders.
Choice C Reason:
Monitoring the client's blood pressure every minute following the first dose of anesthetic solution is appropriate. Epidural anesthesia can potentially cause hypotension (low blood pressure), which is a common side effect. Therefore, close monitoring of the client's blood pressure is crucial, especially following the administration of the initial dose of the anesthetic solution. The goal is to promptly detect and manage any decrease in blood pressure to ensure the well-being of both the mother and the baby.
Choice D Reason:
Ensuring the client has been NPO (nothing by mouth) for 4 hours prior to the placement of the epidural and the first dose of anesthetic solution is not a specific requirement for epidural anesthesi
A. NPO status is more relevant to surgical procedures involving general anesthesia and is not typically a strict requirement for epidural placement.
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Related Questions
Correct Answer is A
Explanation
The correct answer is A. Assist the client to turn onto her side.
A. Assisting the client to turn onto her side is the correct intervention. This is because the client's blood pressure is low, and turning onto the side helps improve blood flow to the uterus, reducing the risk of supine hypotension.
B. Assisting the client to an upright position is not the priority in this case. The client is at risk for supine hypotension, and a lateral position is more appropriate.
C. Preparing for a cesarean birth is not indicated based solely on the blood pressure reading. Turning the client onto her side and monitoring the blood pressure response are appropriate initial actions.
D. Preparing for an immediate vaginal delivery is not indicated based solely on the blood pressure reading. The client's condition may improve with positional changes, and further assessment is needed.
Correct Answer is D
Explanation
A. Brownish vaginal discharge may indicate the presence of old blood or mucus and is not necessarily a cause for concern in the absence of other signs or symptoms.
B. Contractions occurring every 4 to 5 minutes are within the normal frequency range during the first stage of labor.
C. Pink mucoid vaginal discharge, also known as the "bloody show," is a common occurrence in early labor and is not typically a cause for immediate concern.
D. Contractions lasting 100 seconds are excessively long and are a cause for concern.
Prolonged contractions can lead to decreased uterine blood flow, impacting fetal oxygenation. Such prolonged contractions should be assessed and addressed promptly.
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