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
Amniotic fluid with meconium noted can indicate fetal distress, but it is not the most immediate priority compared to fetal heart tones.
Choice B rationale
A maternal temperature of 38.3°C (101°F) can indicate infection, but it is not the most immediate priority compared to fetal heart tones.
Choice C rationale
Foul-smelling vaginal discharge can indicate infection, but it is not the most immediate priority compared to fetal heart tones.
Choice D rationale
Fetal heart tones of 98/min indicate fetal bradycardia, which is a sign of fetal distress and requires immediate intervention to ensure the well-being of the fetus.
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.