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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 D

Explanation

Choice A rationale

Using a breast pump can help maintain milk supply if the client plans to return to work, but it does not directly prevent mastitis.

Choice B rationale

Covering the breasts immediately after feedings is not necessary and does not prevent mastitis. Proper hygiene and feeding techniques are more important.

Choice C rationale

Wearing an underwire bra can restrict milk flow and increase the risk of mastitis. A well-fitting, non-restrictive bra is recommended.

Choice D rationale

Washing nipples with soap and water daily can cause dryness and irritation, increasing the risk of mastitis. It is better to clean the nipples with water only and ensure proper latch and feeding techniques. .

Correct Answer is C

Explanation

Choice A rationale

Agitation is not a common adverse effect of magnesium sulfate therapy. It is more likely to be caused by other factors.

Choice B rationale

Polyuria, or excessive urination, is not a common adverse effect of magnesium sulfate therapy. It is more likely to be caused by other factors.

Choice C rationale

Hyporeflexia, or diminished reflexes, is a significant adverse effect of magnesium sulfate therapy. It indicates magnesium toxicity and requires immediate attention.

Choice D rationale

Tachypnea, or rapid breathing, is not a common adverse effect of magnesium sulfate therapy. It is more likely to be caused by other factors.

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