A nurse is caring for a client who is in labor and has received an epidural. Which of the following actions should the nurse take?
Decrease the maintenance infusion rate of IV fluid.
Have protamine sulfate available at the bedside.
Reposition the client side-to-side each hour.
Monitor the client for hypertension
The Correct Answer is C
A. Decrease the maintenance infusion rate of IV fluid. Epidural anesthesia can cause hypotension, so IV fluids are often used to help maintain blood pressure. Reducing the fluid rate may increase the risk of hypotensive episodes.
B. Have protamine sulfate available at the bedside. Protamine sulfate is the antidote for heparin, not relevant to epidural anesthesia. It is not required in the management of epidural-related side effects.
C. Reposition the client side-to-side each hour. Frequent repositioning helps prevent pressure injuries, promotes fetal oxygenation, and encourages effective labor progression. It also aids in the distribution of the anesthetic agent.
D. Monitor the client for hypertension. Hypotension, not hypertension, is a common adverse effect of epidural anesthesia due to vasodilation and decreased peripheral resistance. Blood pressure should be monitored closely for drops.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Diphenhydramine. Urticaria (hives) is a common allergic reaction often caused by medications like antibiotics. Diphenhydramine, an antihistamine, is used to treat allergic reactions by blocking histamine receptors, reducing itching, swelling, and rash.
B. Hydralazine. This is an antihypertensive medication used to treat high blood pressure, not allergic reactions. It has no effect on histamine or allergic symptoms.
C. Naloxone. Naloxone is an opioid antagonist used to reverse opioid overdose. It does not treat allergic reactions like urticaria unless the cause is opioid-induced (which is not indicated here).
D. Protamine. Protamine is used to reverse the effects of heparin. It has no role in treating allergic reactions to antibiotics.
Correct Answer is C
Explanation
A. Remove the safety inspection sticker before plugging in the IV pump. The safety inspection sticker is proof that the equipment has passed a required check. It should not be removed, as doing so may violate facility policies and regulatory standards.
B. Grasp the IV pump cord when unplugging it from the electrical outlet. Pulling on the cord rather than the plug itself can damage the cord or outlet and pose an electrical hazard. Always unplug by gripping the plug directly.
C. Check the cords of the IV pump for fraying. Inspecting cords for fraying or damage is essential before using any electrical equipment. Damaged cords can lead to electric shock, equipment failure, or fire, and must be reported and replaced.
D. Ensure that the electric outlet has two prongs for the IV pump. Medical equipment should be plugged into a three-pronged (grounded) outlet to prevent electrical shock. Two-prong outlets are not grounded and are inappropriate for hospital-grade devices.
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