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A nurse is assisting with the care of a client who is in labor and has an epidural infusion for pain management.The client’s blood pressure is 80/40 mm Hg. Which of the following actions should the nurse take?

A.

Place the client in knee-chest position.

B.

Administer methylergonovine IM.

C.

Give a bolus of lactated Ringer’s.

D.

Assist the client to empty her bladder.

Answer and Explanation

The Correct Answer is C

Choice A rationale

 

Placing the client in the knee-chest position is not appropriate for managing hypotension caused by an epidural infusion. This position does not effectively improve blood pressure.

 

Choice B rationale

 

Administering methylergonovine IM is not appropriate for managing hypotension caused by an epidural infusion. Methylergonovine is used to manage postpartum hemorrhage, not hypotension.

 

Choice C rationale

 

Giving a bolus of lactated Ringer’s is the appropriate action to manage hypotension caused by an epidural infusion. This helps to increase blood volume and improve blood pressure.

 

Choice D rationale

 

Assisting the client to empty her bladder is important, but it is not the immediate priority in managing hypotension caused by an epidural infusion.


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View Related questions

Correct Answer is C

Explanation

Choice A rationale

Assessing the client’s socioeconomic status is important for understanding their overall health and access to resources, but it is not directly related to providing information about contraception.

Choice B rationale

Selecting the best method of contraception for the client is not the nurse’s role. The decision should be made by the client based on their individual preferences and health considerations.

Choice C rationale

Performing unbiased teaching is essential for providing accurate and comprehensive information about available methods of contraception. The nurse should present all options without imposing personal beliefs or preferences.

Choice D rationale

Providing information on all available methods is important, but it should be done in an unbiased manner. The nurse should ensure that the client has all the necessary information to make an informed decision.

Correct Answer is A

Explanation

Choice A rationale

Repositioning the newborn every 2 to 3 hours is essential during phototherapy to ensure that all areas of the skin are exposed to the light. This helps in the effective breakdown of bilirubin and prevents pressure sores.

Choice B rationale

Monitoring the newborn’s blood glucose level every 2 hours is not a standard intervention for phototherapy. While monitoring glucose levels is important in certain conditions, it is not directly related to the management of hyperbilirubinemia.

Choice C rationale

Applying a water-based ointment to the newborn’s skin every 4 to 6 hours is not recommended during phototherapy. Ointments can block the light from reaching the skin, reducing the effectiveness of the treatment.

Choice D rationale

Giving the newborn 30 mL of distilled water after each feeding is not a recommended practice. Hydration is important, but it should be done through breastfeeding or formula feeding, not distilled water.

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