A client in labor with their second child is requesting epidural anesthesia.
Consent forms have already been signed, and admission paperwork is complete.
Which of the following is a priority nursing intervention before epidural anesthesia is initiated?
Place the client in the fetal position on the table and keep them steady so that they won't move during the procedure.
Prepare a sterile field with the supplies and medications that will be needed.
Review the client's medical history and laboratory results and interview them to confirm all information is accurate and up to date.
Administer a fluid bolus through the IV line to reduce the risk of hypotension.
The Correct Answer is D
Choice A rationale
While positioning the client is a crucial step for the procedure, it is not the first priority. The client is positioned after the preliminary steps, such as administering the fluid bolus, are completed. The fetal position is used to open the intervertebral spaces, allowing for easier needle insertion. However, the first priority is to prevent a known and common complication.
Choice B rationale
Preparing a sterile field is a necessary step for any invasive procedure to prevent infection. The supplies are prepared while the client is getting ready for the procedure. However, the priority intervention is focused on the client's physiological safety and preventing a known and common complication, which takes precedence over setting up the sterile field.
Choice C rationale
Reviewing the client's medical history and lab results is part of the initial admission process and is necessary to ensure the client is a suitable candidate for the procedure. This is done before the decision is made to proceed with the epidural. However, the priority intervention immediately before the procedure is a physiological intervention to prevent a potential complication.
Choice D rationale
Epidural anesthesia can cause vasodilation and a rapid drop in blood pressure due to the blockade of sympathetic nerves. A fluid bolus, typically 500-1000 mL of an isotonic solution, is administered to increase intravascular volume and preload, which helps to counteract this potential hypotensive effect. Preventing maternal hypotension is a priority because it can lead to decreased placental perfusion and fetal distress.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D","E"]
Explanation
Choice A rationale
Documenting a family history of allergies is important for a complete health history, but it is not a direct documentation of the patient's own reported allergies. The question asks what information to document regarding a patient's reported allergies, so the focus is on the patient's personal experience, not that of their family.
Choice B rationale
The type of allergic reaction is crucial information to document. This helps in distinguishing between a true anaphylactic reaction and a side effect or intolerance. Documenting the specific signs and symptoms, such as rash, hives, or shortness of breath, provides vital information for preventing future exposures and guiding appropriate treatment if one occurs.
Choice C rationale
The medication names are essential to document to prevent future exposure to the same drug. This ensures that the patient does not receive the offending medication again, which is a primary safety measure. It is a fundamental component of a complete allergy record to specify the substance that caused the reaction.
Choice D rationale
Documentation of Epi Pen use is critical as it indicates a severe, anaphylactic reaction requiring an emergency intervention. This information alerts providers to the high risk of a life-threatening allergic response and the need for preparedness, such as having epinephrine available for future exposure.
Choice E rationale
The date of the allergic reaction should be documented to provide a chronological history. This helps in understanding the timeline of the allergy and can be useful for determining if an allergy has changed over time or for correlating the reaction with a specific exposure
Correct Answer is C
Explanation
Choice A rationale
Adjusting the intravenous fluid infusion rate is not the immediate priority after an amniotomy. This action is not directly related to the most critical and immediate potential complication of this procedure, which is a change in the fetal heart rate. The primary concern is the potential for umbilical cord prolapse, which can lead to fetal hypoxia.
Choice B rationale
Providing a clean gown and linens is important for client comfort and hygiene, but it is not the immediate priority. The nurse must first ensure the safety of the fetus by assessing for complications that can arise from the procedure, such as umbilical cord compression or prolapse, which can lead to fetal distress and requires immediate intervention.
Choice C rationale
The immediate priority after an amniotomy is to assess the fetal heart rate. The sudden release of amniotic fluid can cause the umbilical cord to prolapse and become compressed, leading to a rapid decrease in blood flow and oxygen to the fetus. This compression results in fetal bradycardia, a critical finding requiring immediate intervention to prevent fetal hypoxia and death.
Choice D rationale
Assisting the client to wash the perineum is a hygiene measure that can be performed after the immediate safety of the fetus has been established. It is not the priority action. The nurse must first rule out any life-threatening complications to the fetus, such as cord prolapse, which is a significant risk following the rupture of membranes.
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