A nurse is caring for a client who is in labor and just received epidural anesthesia. The client's blood pressure is 90/50 mm Hg. Which of the following actions should the nurse take?
Turn the client onto their side.
Initiate an amnio-infusion for the client.
Administer naloxone to the client.
Monitor the client's blood pressure every 15 min.
The Correct Answer is A
Epidural anesthesia can cause hypotension in the mother, which can decrease blood flow to the fetus. Turning the client onto their side can help to improve blood flow to the fetus by reducing the pressure of the uterus on the vena cava and increasing venous return to the heart.
Option B is incorrect because an amnio-infusion is not indicated for hypotension related to epidural anesthesia.
Option C is also incorrect because naloxone is a medication used to reverse the effects of opioid medications and would not be appropriate for treating hypotension related to epidural anesthesia.
Option D is partially correct but does not address the immediate need to improve blood flow to the fetus. The nurse should monitor the client's blood pressure regularly but should also take immediate action to turn the client onto their side to improve blood flow.
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Related Questions
Correct Answer is A
Explanation
An episiotomy is a surgical incision made in the perineum to enlarge the vaginal opening during delivery. A midline episiotomy is an incision made in the midline of the perineum, which has been associated with a higher risk of infection than a mediolateral episiotomy.
Option B is incorrect because meconium-stained fluid does not necessarily place the postpartum client at increased risk for infection. However, it can indicate that the fetus was stressed during delivery and may require additional monitoring after birth.
Option C is also incorrect because gestational hypertension, while it can lead to complications during pregnancy and delivery, does not necessarily place the postpartum client at increased risk for infection.
Option D is also incorrect because placenta previa is a condition in which the placenta is low-lying and can partially or completely cover the cervix. It can cause bleeding during pregnancy and delivery but does not necessarily place the postpartum client at increased risk for infection.
Correct Answer is D
Explanation
The nurse should withhold the terbutaline and report to the provider if the client's blood pressure is 88/58 mm Hg. Terbutaline can cause hypotension, and a blood pressure reading in this range indicates the client is already experiencing low blood pressure. The provider may need to adjust the medication dosage or consider an alternative medication.
The other findings are within normal ranges and would not require withholding the medication or reporting to the provider:
Fasting blood glucose of 75 mg/dL is within the normal range.
FHR of 120/min is within the normal fetal heart rate range.
Urinary output of 40 ml/hr is within normal range, although it should be monitored for any signs of decreased urine output as this could indicate dehydration.
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