A laboring client has just received an epidural.
Ten minutes after the epidural placement, the client begins to feel dizzy and lightheaded and the BP is 92/54. What should be the nurse’s first response?
Perform a vaginal examination.
Turn the client onto her side.
Catheterize the client.
Decrease the IV fluid rate.
The Correct Answer is B
Choice A rationale:
Performing a vaginal exam is not the priority intervention for a client experiencing hypotension after an epidural. While a vaginal exam may be necessary to assess cervical dilation and fetal station, it does not address the underlying cause of the client's hypotension.
Additionally, a vaginal exam could potentially worsen the client's hypotension by stimulating the vagus nerve, which can lead to decreased heart rate and blood pressure.
Therefore, it is not the most appropriate initial response in this situation.
Choice B rationale:
Turning the client onto her side is the most appropriate initial response to hypotension after an epidural. This position helps to increase venous return to the heart, which can improve cardiac output and blood pressure.
It also helps to prevent aortocaval compression, which can occur when the pregnant uterus compresses the inferior vena cava, reducing blood flow back to the heart.
By turning the client onto her side, the nurse can quickly and easily address the underlying cause of the hypotension and help to improve the client's hemodynamic status.
Choice C rationale:
Catheterizing the client may be necessary if the client is unable to void spontaneously, but it is not the priority intervention for hypotension after an epidural.
Urinary retention can occur after an epidural, but it is not typically the cause of hypotension in this setting.
Therefore, catheterization would not be the most appropriate initial response.
Choice D rationale:
Decreasing the IV fluid rate may be necessary if the client is experiencing fluid overload, but it is not the priority intervention for hypotension after an epidural.
In fact, decreasing the IV fluid rate could potentially worsen the hypotension by reducing the circulating blood volume.
Therefore, it is not the most appropriate initial response.
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Related Questions
Correct Answer is B
Explanation
Choice A rationale:
This statement is incorrect. The risk factor for a genetic disorder can vary depending on the specific disorder and the family history. For example, the risk of having a child with an autosomal recessive disorder is higher if there is a history of the disorder in the family.
Additionally, some genetic disorders have a higher risk of recurrence than others. For example, the risk of having a child with cystic fibrosis is 25% if both parents are carriers of the gene.
It's crucial for nurses to be aware of the varying risk factors associated with different genetic disorders to provide accurate information and counseling to families.
Choice C rationale:
This statement is also incorrect. The risk of a disorder involving maternal ingestion of drugs being repeated in the second child depends on several factors, including the specific drug, the dose, and the timing of exposure.
It cannot be generalized to a one in four chance for all drug-related disorders. Nurses should consult with appropriate resources and specialists to determine the specific risks associated with different drugs and exposures.
Choice D rationale:
This statement is incorrect for autosomal dominant disorders. With an autosomal dominant disorder, the likelihood of the second child also having the condition is 50%, not 100%. Each child has a 50% chance of inheriting the affected gene from the affected parent.
It's essential for nurses to understand the inheritance patterns of different genetic disorders to provide accurate information and support to families.
Choice B rationale:
This statement is correct. An autosomal recessive disease carries a one in eight risk of the second child also having the disorder. This is because both parents must be carriers of the affected gene for a child to inherit the disorder.
If both parents are carriers, there is a 25% chance that each child will inherit two copies of the affected gene and have the disorder. However, there is also a 50% chance that each child will inherit only one copy of the affected gene and be a carrier, and a 25% chance that each child will inherit two normal copies of the gene and not be affected.
Correct Answer is C
Explanation
Rationale for Choice A:
Encouraging the woman to rest between contractions can promote relaxation and help conserve energy, but it does not directly address the mechanisms of pain transmission as explained by the gate-control theory. Rest can have indirect benefits for pain management, but it does not directly interfere with pain signals in the same way that massage does.
Rationale for Choice B:
Administering prescribed medication can effectively block pain signals, but it does not rely on the principles of the gatecontrol theory. Medications typically work through pharmacological mechanisms that target pain receptors or neurotransmitters, rather than by competing with pain signals at the spinal cord level.
Rationale for Choice D:
Changing the woman's position can sometimes alleviate discomfort by shifting pressure or encouraging fetal movement, but it does not directly apply the gate-control theory either. Position changes can offer some physical relief, but they do not directly modulate the transmission of pain signals.
Rationale for Choice C:
Massaging the woman's back directly aligns with the gate-control theory of pain management. This theory proposes that nonpainful sensory input can effectively compete with pain signals, preventing them from reaching the brain. The following mechanisms explain how massage applies this theory:
Stimulation of non-painful nerve fibers: Massage activates large-diameter nerve fibers that transmit touch, pressure, and vibration sensations. These signals travel faster than pain signals and can effectively "close the gate" at the spinal cord, preventing pain signals from ascending to the brain.
Release of endorphins: Massage can stimulate the release of endorphins, the body's natural pain relievers. Endorphins bind to opioid receptors in the brain and spinal cord, reducing the perception of pain.
Reduction of muscle tension: Labor pain often involves muscle tension and spasms. Massage can help relax tense muscles, which can indirectly reduce pain by decreasing muscle ischemia and the release of pain-provoking substances.
Promotion of relaxation and distraction: Massage can induce a state of relaxation and provide a distraction from pain. This psychological effect can further contribute to pain relief by reducing anxiety and focusing attention on pleasant sensations.
Conclusion:
Massage offers a non-pharmacological, evidence-based approach to pain management that directly aligns with the gate-control theory. By stimulating non-painful sensory input, promoting relaxation, and releasing endorphins, massage effectively interrupts pain signals and provides significant relief for women in labor.
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