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 correct answer is: d. Right lower
Choice A: Right upper
Reason: The right upper quadrant is not typically where fetal heart tones are auscultated when the fetal back is on the right side and the head is in the lower part of the uterus. This area is more likely to be associated with the breech presentation if the fetus’s head is in the fundus.
Choice B: Left upper
Reason: The left upper quadrant would be considered if the fetal back was on the left side and the head was in the fundus. Since the nurse palpated the fetal back on the right side, this option is not applicable.
Choice C: Left lower
Reason: The left lower quadrant would be relevant if the fetal back was on the left side and the head was in the lower part of the uterus. Given the fetal back is on the right side, this is not the correct location.
Choice D: Right lower
Reason: The correct answer is the right lower quadrant. When the nurse palpates a round, firm, movable part (likely the head) in the fundus and a long, smooth surface (the back) on the right side, it indicates that the fetus is in a cephalic (head-down) position with its back on the right. Therefore, the fetal heart tones are best auscultated in the right lower quadrant.
Correct Answer is D
Explanation
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.
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