A nurse is assisting with the care of a client who had an epidural anesthesia block during the early stages of labor. The client's blood pressure is 80/40 mm Hg and the fetal heart recording is 140/min. Which of the following actions should the nurse take first?
Place the client in a lateral position.
Notify the provider.
Increase IV fluid rate.
Elevate the legs.
The Correct Answer is A
Choice A reason:
Placing the client in a lateral position is the first action the nurse should take, as it can improve maternal and fetal circulation by relieving pressure on the inferior vena cava. The client's blood pressure is low, which can indicate hypotension due to epidural anesthesia or supine hypotension syndrome.
Choice B reason:
Notifying the provider is an important action, as it can facilitate further interventions and monitoring for the client and the fetus. However, this is not the first action the nurse should take, as it does not address the immediate problem of hypotension.
Choice C reason:
Increasing IV fluid rate is an important action, as it can expand blood volume and increase blood pressure. However, this is not the first action the nurse should take, as it may not be effective if the client is in a supine position.
Choice D reason:
Elevating the legs is an important action, as it can enhance venous return and increase blood pressure. However, this is not the first action the nurse should take, as it may worsen supine hypotension syndrome by increasing pressure on the inferior vena cava.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Amniotic fluid in the vaginal vault indicates that the membranes have ruptured, but this does not necessarily mean that the client is in labor. Some women may have a slow leak of amniotic fluid for hours or days before labor begins. Rupture of membranes also increases the risk of infection, so the nurse should monitor the client's temperature and fetal heart rate.
Choice B reason: Contractions every 3 to 4 minutes are a sign of labor, but they are not enough to confirm it. The nurse should also assess the duration and intensity of the contractions, as well as the client's response to them. Some women may have false labor contractions, also known as Braxton Hicks contractions, which are irregular, mild, and do not cause cervical changes.
Choice C reason: Pain just above the navel is not a typical sign of labor. It may indicate other problems, such as placental abruption, uterine rupture, or fetal distress. The nurse should report this finding to the nurse midwife and check for other signs of bleeding, shock, or fetal compromise.
Choice D reason: Cervical dilation is the most reliable indicator of labor. It means that the cervix is opening and thinning out to allow the passage of the fetus. The nurse should measure the cervical dilation in centimeters and document it along with the station and effacement of the cervix.
Correct Answer is B
Explanation
Choice A reason:
A warm sitz bath can promote healing and comfort, but it is not recommended until 24 hr after delivery, as it can increase swelling and bleeding.
Choice B reason:
An ice pack can reduce inflammation and pain by causing vasoconstriction and numbing the area. It should be applied for 20 minutes at a time, with a cloth barrier between the skin and the ice.
Choice C reason:
A soft pillow under the client's butocks can increase pressure on the perineum and worsen the pain. The client should be encouraged to lie on her side or sit in a semi-Fowler's position.
Choice D reason:
A heating lamp can dry out the wound and delay healing. It can also cause burns and discomfort. It should be avoided for episiotomy care.
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