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A nurse is caring for a client who is in active labor and is scheduled to receive epidural anesthesia.
Which of the following actions should the nurse take?

A.

Monitor blood pressure every 30 minutes following epidural placement.

B.

Administer lactated Ringer's 500 mL bolus via intermittent IV infusion prior to epidural placement.

C.

Administer oxygen via nasal cannula at 2 L/min prior to epidural placement.

D.

Reposition the client every hour following epidural placement.

Answer and Explanation

The Correct Answer is B

Choice A rationale

Monitoring blood pressure every 30 minutes following epidural placement is important but not the initial action. Epidural anesthesia can lead to a sudden drop in blood pressure, so frequent monitoring is crucial. However, the initial step should focus on preventing hypotension.

Choice B rationale

Administering lactated Ringer's 500 mL bolus via intermittent IV infusion prior to epidural placement helps in maintaining blood pressure. Epidural anesthesia can cause vasodilation, leading to hypotension. Preloading with fluids ensures adequate blood volume and reduces the risk of a significant drop in blood pressure.

Choice C rationale

Administering oxygen via nasal cannula at 2 L/min prior to epidural placement is not necessary unless the client has respiratory complications. Oxygen supplementation is used to treat or prevent hypoxia, which is not a primary concern in this scenario.

Choice D rationale

Repositioning the client every hour following epidural placement is important to ensure even distribution of the anesthetic and prevent pressure sores. However, this is not the initial action to take for preventing hypotension.


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Related Questions

Correct Answer is C

Explanation

Choice A rationale

Gaining 2 pounds per week throughout the rest of pregnancy is excessive and not recommended. Normal weight gain is approximately 1 pound per week in the second and third trimesters.

Choice B rationale

Dieting during pregnancy can lead to inadequate nutrient intake for both the mother and the developing fetus. It is essential to focus on a balanced diet rather than trying to lose weight.

Choice C rationale

Meeting with a dietitian can help the client assess their nutritional needs and develop a healthy eating plan to support their pregnancy, ensuring both maternal and fetal health.

Choice D rationale

Eating an additional 700 calories per day is too high. Generally, an additional 300-500 calories per day is recommended during the second and third trimesters to support pregnancy. .

Correct Answer is A

Explanation

The nurse should identify that contractions occurring every 5 minutes require follow-up for several reasons:

  1. Preterm Labor Risk: At 32 weeks of gestation, regular contractions every 5 minutes could indicate the onset of preterm labor. This is concerning because preterm labor can lead to preterm birth, which poses significant risks to the baby's health and development.
  2. Frequency and Intensity: These contractions are occurring frequently (every 5 minutes) and are described as stronger than usual Braxton Hicks contractions. This frequency and the strength of the contractions are unusual for Braxton Hicks, which are typically irregular and less intense.
  3. Effacement and Cervical Changes: Although the cervix is closed, it is 80% effaced. Effacement means the cervix is thinning, which, in combination with regular contractions, may indicate that the body is preparing for labor.
  4. Urinary Leakage: The client also reported urinary leakage earlier in the day, which could be a sign of ruptured membranes (water breaking). This, combined with regular contractions, increases the need for careful monitoring.

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