A patient in labor has just received an epidural block.
What is the most important nursing intervention?
Monitor the maternal pulse for possible bradycardia.
Monitor the fetus for possible tachycardia.
Monitor the maternal blood pressure for possible hypotension.
Limit parenteral fluids.
The Correct Answer is C
Choice A rationale
Bradycardia, or a slow heart rate, is not a typical immediate side effect of an epidural block. The primary cardiovascular risk is vasodilation below the level of the block, which can cause a sudden decrease in systemic vascular resistance and a drop in blood pressure. Bradycardia is more commonly associated with other conditions, not as a direct primary effect of epidural administration.
Choice B rationale
Fetal tachycardia is not an expected or most important immediate adverse effect of an epidural block. While maternal fever and subsequent fetal tachycardia can occur later with epidural use, the most critical immediate maternal side effect that requires vigilant monitoring is hypotension, which can lead to decreased placental perfusion and subsequent fetal distress.
Choice C rationale
The most important nursing intervention following an epidural block is to monitor the patient's blood pressure for hypotension. The epidural causes vasodilation of the blood vessels below the level of the block, leading to a decrease in systemic vascular resistance and venous return. This can cause a sudden and significant drop in blood pressure, which can decrease placental perfusion and compromise fetal oxygenation.
Choice D rationale
Limiting parenteral fluids is not an appropriate intervention; in fact, the opposite is true. A bolus of intravenous fluids is often administered before the epidural to expand the maternal blood volume and help mitigate the risk of hypotension. Limiting fluids would exacerbate the risk of hypotension and its associated complications for both the mother and fetus. *.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["2.5"]
Explanation
Step 1: The total units available are 100 U in a 10 mL vial.
Step 2: Calculate the concentration of the medication: 100 U ÷ 10 mL = 10 U/mL.
Step 3: The ordered dose is 25 U.
Step 4: Calculate the volume to administer: 25 U ÷ (10 U/mL) = 2.5 mL. Final calculated answer: 2.5.
Correct Answer is D
Explanation
Choice A rationale
The statement, "I am glad they are giving me something to try to stop my labor for now," shows a correct understanding of nifedipine's role as a tocolytic agent. Nifedipine, a calcium channel blocker, works by inhibiting the influx of calcium into uterine muscle cells, which is necessary for contraction. This effectively slows or stops preterm labor, giving time for corticosteroids to work.
Choice B rationale
The statement, "This medication can lower my blood pressure to dangerous levels," shows a correct understanding of a major side effect of nifedipine. As a calcium channel blocker, it causes vasodilation, which can lead to a drop in blood pressure. The patient should be monitored for hypotension and advised to report symptoms like dizziness or lightheadedness.
Choice C rationale
The statement, "I will let you know if I feel dizzy," indicates a correct understanding of a common symptom associated with the hypotensive effect of nifedipine. Dizziness is a direct result of decreased cerebral blood flow due to lower blood pressure. Reporting this symptom allows the nurse to intervene and prevent falls or other complications.
Choice D rationale
The statement, "Nifedipine should help mature my baby's lungs," is incorrect. Nifedipine is a tocolytic used to stop uterine contractions. The medication used to promote fetal lung maturity is a corticosteroid, such as betamethasone. This statement indicates a need for additional teaching to differentiate the purpose of these two classes of medications.
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