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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Fetal position during the first trimester is not definitively determined through ultrasound. While the gestational sac and fetal pole can be visualized, the fetus is still quite small and has ample space to move within the amniotic sac. This makes it challenging to accurately ascertain its position.
Reliable assessment of fetal position typically occurs later in pregnancy, usually between 34 and 36 weeks gestation. At this point, the fetus is larger and less mobile, allowing for a clearer assessment of its position through ultrasound.
The early determination of fetal position in the first trimester is not a primary goal of ultrasound. It is more focused on establishing pregnancy viability, gestational age, and detecting any potential abnormalities.
Choice B rationale:
Ultrasound in the first trimester can reliably detect multiple gestations. It can visualize the presence of multiple gestational sacs or fetal poles, clearly indicating whether a woman is carrying twins, triplets, or more.
Early identification of multiple gestations is crucial for optimal pregnancy management. It allows healthcare providers to tailor prenatal care, monitor for potential complications associated with multiple pregnancies, and plan for appropriate delivery. Choice C rationale:
Ultrasound in the first trimester can assist in detecting certain maternal abnormalities that could impact pregnancy. These may include:
Uterine abnormalities, such as fibroids or structural defects
Ovarian cysts
Ectopic pregnancies (where the embryo implants outside the uterus)
Gestational trophoblastic disease (abnormal growth of tissue inside the uterus)
Early identification of these maternal abnormalities allows for timely intervention and management, ensuring the best possible outcomes for both mother and fetus.
Choice D rationale:
Confirming pregnancy is a primary reason for ultrasound in the first trimester. It can visualize the gestational sac, which contains the developing embryo and confirms the presence of a pregnancy.
Ultrasound can also detect the fetal heartbeat, which typically becomes visible between 6 and 8 weeks gestation. This provides further confirmation of a viable pregnancy.
Correct Answer is A
Explanation
Choice A rationale:
Diagnosing a fetus with a genetic disorder is outside the scope of practice for nurses. This task requires specialized training and expertise in genetics and diagnostic procedures, typically held by physicians such as geneticists, maternal-fetal medicine specialists, or genetic counselors.
Nurses play a crucial role in genetic counseling, but their responsibilities focus on:
Educating patients about genetic risks and testing options.
Obtaining informed consent for genetic testing.
Coordinating genetic testing appointments and procedures.
Providing emotional support and counseling to patients and families.
Facilitating communication between patients, families, and other healthcare providers.
Advocating for patients' rights and needs.
Choice B rationale:
Providing emotional support is a core component of nursing care, including genetic counseling. Nurses are trained to provide empathetic and compassionate support to patients and families who are facing the challenges of genetic conditions. This includes:
Active listening and validation of feelings.
Assisting with coping mechanisms and stress management.
Connecting patients with support groups and resources.
Promoting resilience and hope.
Choice C rationale:
Identifying at-risk families is a vital role for nurses in genetic counseling. By recognizing families with a history of genetic disorders or those who exhibit risk factors, nurses can initiate early intervention and preventive measures. This includes:
Taking a thorough family history.
Assessing risk factors and potential genetic concerns.
Educating families about their potential risks.
Referring families for genetic counseling and testing as appropriate.
Choice D rationale:
Collaboration with other healthcare providers and referral for specialized care are essential aspects of genetic counseling. Nurses often work within interdisciplinary teams to provide comprehensive care for patients with genetic concerns. This includes:
Communicating with geneticists, genetic counselors, and other specialists.
Coordinating referrals for genetic testing, counseling, and treatment.
Ensuring continuity of care across different healthcare settings.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today