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?
Place the client in knee-chest position.
Administer methylergonovine IM.
Give a bolus of lactated Ringer’s.
Assist the client to empty her bladder.
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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Correct Answer is C
Explanation
Choice A rationale
A Papanicolaou test, commonly known as a Pap smear, is used to detect cervical cancer and precancerous changes in the cervix. It does not detect herpes simplex type 1. Herpes simplex virus (HSV) testing is typically done through a swab of the lesion or blood tests to detect antibodies.
Choice B rationale
A glucose tolerance test is performed during pregnancy to screen for gestational diabetes, not to predict hyperglycemia in the baby. This test helps identify how well the mother’s body is managing glucose and ensures that both mother and baby remain healthy during pregnancy.
Choice C rationale
A multiple marker screening, also known as a triple or quad screen, is performed during pregnancy to identify potential neural tube defects, such as spina bifida, and chromosomal abnormalities like Down syndrome. This test measures specific substances in the mother’s blood to assess the risk of these conditions.
Choice D rationale
Group B streptococcus (GBS) screening is performed to detect the presence of GBS bacteria in the mother’s body, not to determine the presence of sexually transmitted infections (STIs). GBS can cause serious infections in newborns, so it is important to identify and treat it before delivery.
Correct Answer is A
Explanation
Choice A rationale
A hemoglobin level of 9.5 g/dL is low for a full-term newborn and should be reported to the provider. Normal hemoglobin levels for newborns range from 14 to 24 g/dL4.
Choice B rationale
A white blood cell count of 10,000/mm³ is within the normal range for a newborn, which is typically between 9,000 and 30,000/mm³4.
Choice C rationale
A glucose level of 60 mg/dL is within the normal range for a newborn, which is typically between 40 and 60 mg/dL4.
Choice D rationale
A platelet count of 225,000/mm³ is within the normal range for a newborn, which is typically between 150,000 and 450,000/mm³4.