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 D
Explanation
Choice A rationale
Administering oxygen may help with symptoms like headache and weakness, but it does not address the underlying issue of poor circulation and potential shock. Elevating the legs is more effective in improving blood flow to vital organs.
Choice B rationale
Offering an ice pack is not appropriate for the symptoms described. The client is showing signs of shock, and an ice pack would not address the underlying issue.
Choice C rationale
Providing a warm blanket may offer comfort, but it does not address the symptoms of shock. Elevating the legs is a more direct intervention to improve circulation and stabilize the client.
Choice D rationale
Elevating the client’s legs helps improve venous return to the heart, increasing cardiac output and stabilizing blood pressure. This is a critical intervention for a client showing signs of shock.
Correct Answer is A
Explanation
Choice A rationale
Eating dry, bland foods in the morning can help alleviate nausea by providing a gentle start to the digestive system. Bland foods like crackers or toast are less likely to irritate the stomach lining and can help absorb stomach acids, reducing the feeling of nausea.
Choice B rationale
Taking an over-the-counter antacid is not recommended for nausea during pregnancy unless prescribed by a healthcare provider. Antacids are typically used to neutralize stomach acid and relieve heartburn, not nausea.
Choice C rationale
Restricting fluids to 1,000 mL/day is not advisable as it can lead to dehydration. Adequate hydration is essential during pregnancy to support the increased blood volume and amniotic fluid.
Choice D rationale
Increasing the intake of fresh fruits is beneficial for overall health but may not specifically address nausea. Some fruits can be acidic and might worsen nausea in some individuals.