A nurse is caring for a client who has maternal hypotension following the placement of an epidural. Which of the following actions should the nurse take?
Position the client in a knee-chest position.
Administer a bolus infusion of lactated Ringer's.
Give terbutaline subcutaneously.
Apply oxygen via a nonrebreather face mask at 2 L/min.
The Correct Answer is B
The correct answer is choice B: Administer a bolus infusion of lactated Ringer’s.
Choice A rationale:
Positioning the client in a knee-chest position is not the standard intervention for maternal hypotension following epidural placement. This position is more commonly associated with cord prolapse or to relieve pressure on the vena cava.
Choice B rationale:
Administering a bolus infusion of lactated Ringer’s is the correct action. Hypotension during epidural analgesia is treated with additional intravenous boluses of crystalloid solution. This helps to increase the circulating blood volume and counteract the vasodilation caused by the epidural.
Choice C rationale:
Terbutaline is a medication used to relax the uterus and prevent premature labor, not for treating hypotension.
Choice D rationale:
Applying oxygen via a nonrebreather face mask at 2 L/min is not the primary treatment for maternal hypotension. Oxygen may be used as a supportive measure if there is evidence of fetal distress or maternal hypoxemia, but the first line of treatment for hypotension is fluid administration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Requesting that the provider insert an intrauterine pressure catheter is not the immediate action the nurse should take when the umbilical cord is palpated during a vaginal examination. The priority is to relieve pressure on the cord and improve fetal oxygenation.
Choice B rationale:
Exerting continuous upward pressure on the presenting part is the correct action when the nurse palpates the umbilical cord during a vaginal examination. This manoeuvre is called "vaginal elevation,”. helps lift the presenting part off the umbilical cord, reducing the risk of cord compression and fetal distress until the provider can take further action.
Choice C rationale:
Initiating oxytocin via continuous IV infusion is not appropriate when the umbilical cord is palpated during a vaginal examination. Oxytocin can cause uterine contractions, potentially further compromising the cord and fetus.
Choice D rationale:
Placing the client in the left-lateral position is not the best immediate action for cord palpation. While the left-lateral position is useful for relieving pressure on the vena cava in cases of supine hypotensive syndrome, the priority here is to relieve cord compression, and upward pressure on the presenting part is more effective.
Correct Answer is C
Explanation
Choice A rationale:
Blood pressure of 136/88 mm Hg should be monitored, but it is not a finding that the nurse needs to urgently report to the provider following the administration of butorphanol. The blood pressure reading is slightly elevated but might be attributed to pain or anxiety during labor.
Choice B rationale:
Moderate fetal heart rate variability is a reassuring sign of fetal well-being and is an expected finding during labor. It does not require immediate reporting to the provider.
Choice C rationale:
Respiratory rate of 100/min is significantly increased and should be reported to the provider following the administration of butorphanol. Respiratory depression is a potential side effect of opioids like butorphanol, and a respiratory rate of 100/min raises concern for potential respiratory compromise.
Choice D rationale:
Urinary output of 120 mL in 2 hours is an acceptable finding during labor and does not require immediate reporting to the provider. Adequate urinary output varies, but generally, 30 mL/hour is considered acceptable during labor.
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