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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
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.
Correct Answer is C
Explanation
Magnesium sulfate is a medication used to prevent and treat seizures in clients with preeclampsia and eclampsia. It is also used to stop preterm labor. However, magnesium sulfate can cause a variety of side effects, including decreased reflexes, which can be a sign of magnesium toxicity. Therefore, it is important for the nurse to monitor the client for signs of toxicity.
Option A is incorrect because a decrease in the frequency of contractions is a desired effect of magnesium sulfate when it is used to stop preterm labor.
Option B is also incorrect because although a blood pressure of 150/100 mm Hg is elevated, it is not an unexpected finding in a client with preeclampsia, and it may actually be considered an improvement if the client's blood pressure was previously higher.
Option D is incorrect because a urinary output of 35 mL/hr is within the normal range for an adult.
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