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 A nurse is caring for a client who is in active labor.

Exhibits

 The nurse is caring for a client following the insertion of an epidural. For each nursing intervention, click to specify if the intervention is essential or contraindicated for the client.​​​​​​

A.

Monitor fetal heart rate.

B.

Place client in left lateral position.

C.

Administer ampicillin IV.

D.

Request a prescription for ephedrine.

E.

Decrease the IV flow rate.

Answer and Explanation

The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"B"}}

  • Monitor fetal heart rate: After epidural placement, continuous fetal heart monitoring is essential due to the risk of uteroplacental hypoperfusion from maternal hypotension, which can alter fetal oxygenation and variability.
  • Place client in left lateral position: This position improves uterine perfusion and prevents vena cava compression, which is especially critical post-epidural to stabilize maternal blood pressure and enhance fetal oxygenation.
  • Administer ampicillin IV: The client tested positive for group B Streptococcus, which requires IV prophylactic antibiotics during labor to prevent neonatal sepsis, making this an essential intervention.
  • Request a prescription for ephedrine: Ephedrine may be required to manage maternal hypotension, a common adverse effect of epidural anesthesia. Early signs like fetal heart rate changes warrant readiness to intervene.
  • Decrease the IV flow rate: Reducing IV fluids post-epidural can worsen hypotension and compromise placental perfusion. Instead, increasing fluids is preferred to support circulating volume and maintain BP.


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Related Questions

Correct Answer is C

Explanation

A. Varicella:Varicella (chickenpox) requires airborne and contact precautions due to its high transmissibility via respiratory droplets and contact with skin lesions. While contact precautions are used, the primary precaution is airborne.

B. Pertussis:Pertussis is transmitted through respiratory droplets, so droplet precautions are the appropriate measure. Contact precautions are not necessary unless there are heavy respiratory secretions contaminating surfaces.

C. Clostridium difficile:Contact precautions are essential for clients with C. difficile due to the spore-forming nature of the bacteria, which can survive on surfaces. Gown and gloves are required when entering the room, and hand hygiene with soap and water is necessary after contact.

D. Mycobacterium tuberculosis:TB is transmitted via airborne particles, requiring airborne precautions and a negative pressure room. Contact precautions are not indicated for TB unless there are additional infections with contact-spread pathogens.

Correct Answer is []

Explanation

  • Opioid intoxication:The client shows hallmark signs of opioid overdose bradypnea, pinpoint pupils, hypothermia, confusion, and hypotension after a long history of oxycodone use and functional decline.
  • Obtain prescription for naloxone:Naloxone is an opioid antagonist that rapidly reverses life-threatening respiratory depression caused by opioid toxicity and should be administered promptly.
  • Prepare to initiate mechanical ventilation:Due to the client's shallow respirations and oxygen saturation of 90% on room air, assisted ventilation may be needed to maintain adequate oxygenation post-naloxone or if unresponsive.
  • Respiratory rate:Hypoventilation is the most critical complication of opioid overdose; frequent monitoring is essential to detect deterioration or improvement following naloxone administration.
  • Pupillary reaction:Constricted pupils are a key indicator of opioid toxicity. Monitoring for dilation after naloxone helps assess the reversal of opioid effects and neurologic improvement.

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