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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
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.
Correct Answer is ["B","C","E","F"]
Explanation
The correct answers are B, C, E, and F.
Rationale for each choice:
- Albuterol
Mechanism of action: Albuterol is a beta-2 agonist that stimulates beta-2 receptors in the cell membranes of skeletal muscle, liver, and adipose tissue. This stimulation causes an increase in intracellular cyclic AMP (cAMP), which activates protein kinase A (PKA). PKA then phosphorylates a number of proteins, including the sodium-potassium ATPase pump. This pump is responsible for transporting potassium ions into cells and out of the bloodstream. By increasing the activity of this pump, albuterol can help to lower serum potassium levels.
Onset of action: Albuterol has a rapid onset of action, typically within 30 minutes.
Duration of action: The duration of action of albuterol is relatively short, usually 4-6 hours.
Dosage: The dosage of albuterol for hyperkalemia is typically 10-20 mg nebulized every 4-6 hours.
Additional considerations: Albuterol can cause tachycardia and tremors. It should be used cautiously in patients with heart disease or hyperthyroidism.
- Kayexalate
Mechanism of action: Kayexalate is a cation exchange resin that binds to potassium ions in the gastrointestinal tract. This prevents the potassium from being absorbed into the bloodstream.
Onset of action: Kayexalate has a relatively slow onset of action, usually 1-2 hours.
Duration of action: The duration of action of Kayexalate is relatively long, usually 4-6 hours.
Dosage: The dosage of Kayexalate for hyperkalemia is typically 15-30 grams orally or rectally every 6 hours.
Additional considerations: Kayexalate can cause constipation and hypocalcemia. It should be used cautiously in patients with bowel obstruction or kidney disease.
- Insulin & dextrose
Mechanism of action: Insulin promotes the movement of potassium into cells, thus lowering serum potassium levels. Dextrose is given along with insulin to prevent hypoglycemia.
Onset of action: Insulin has a rapid onset of action, typically within 30 minutes.
Duration of action: The duration of action of insulin is relatively short, usually 4-6 hours.
Dosage: The dosage of insulin for hyperkalemia is typically 10 units of regular insulin IV push, followed by an infusion of 5-10 units per hour. The dosage of dextrose is typically 50 grams IV push, followed by an infusion of 10% dextrose at 100 mL/hour.
Additional considerations: Insulin can cause hypoglycemia. It should be used cautiously in patients with diabetes mellitus.
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