A nurse is attending to a patient in labor who has received an epidural anesthesia block. The patient’s blood pressure reads 80/40 mm Hg and the fetal heart rate is 140/min.
What should be the nurse’s immediate course of action?
Monitor vital signs every 5 minutes.
Elevate the patient’s legs.
Notify the healthcare provider.
Position the patient laterally.
Position the patient laterally.
The Correct Answer is D
If a patient in labor who has received an epidural anesthesia block has a blood pressure reading of 80/40 mm Hg, the nurse’s immediate course of action should be to position the patient laterally. This helps to maximize venous return and cardiac output, thereby improving maternal blood pressure and fetal perfusion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The priority finding for a nurse caring for a client receiving opioid epidural analgesia during labor would be a blood pressure of 80/56 mm Hg. This could indicate hypotension, a known side effect of epidural analgesia. Hypotension can lead to decreased perfusion to vital organs, including the placenta, potentially compromising the fetus. Immediate interventions might include positioning the patient on her side, increasing the rate of IV fluids, and notifying the healthcare provider.
Correct Answer is D
Explanation
Choice A rationale
The umbilical cord typically contains two arteries and one vein, not one artery and one vein. The umbilical arteries carry deoxygenated blood from the fetus to the placenta, while the umbilical vein carries oxygenated blood from the placenta to the fetus.
Choice B rationale
The umbilical cord typically contains two arteries and one vein, not two veins and one artery. The umbilical arteries carry deoxygenated blood from the fetus to the placenta, while the umbilical vein carries oxygenated blood from the placenta to the fetus.
Choice C rationale
The umbilical cord typically contains two arteries and one vein, not two arteries and two veins. The umbilical arteries carry deoxygenated blood from the fetus to the placenta, while the umbilical vein carries oxygenated blood from the placenta to the fetus.
Choice D rationale
The umbilical cord typically contains two arteries and one vein. The umbilical arteries carry deoxygenated blood from the fetus to the placenta, while the umbilical vein carries oxygenated blood from the placenta to the fetus.
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