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 B
Explanation
Choice A rationale
The statement about the partner wanting to help but not planning for the baby indicates a lack of acceptance and preparation for the pregnancy. It suggests that the adolescent and their partner may not have fully embraced the reality of the pregnancy.
Choice B rationale
Missing soda but acknowledging that it is better for the baby indicates that the adolescent is making sacrifices and changes for the benefit of the baby. This behavior reflects acceptance of the pregnancy and a willingness to prioritize the baby’s health.
Choice C rationale
Being upset about having to quit school when the baby comes indicates that the adolescent is struggling with the impact of the pregnancy on their life plans. This statement suggests a lack of acceptance and difficulty in adjusting to the pregnancy.
Choice D rationale
Expecting the parents to raise the baby due to being young indicates a lack of acceptance and responsibility for the pregnancy. It suggests that the adolescent may not be fully prepared to take on the role of a parent.
Correct Answer is B
Explanation
Choice A rationale
Feeding the baby six times a day is not sufficient. Newborns typically need to be fed 8-12 times in 24 hours to ensure they receive adequate nutrition and to establish a good milk supply.
Choice B rationale
Recognizing that the baby sucking on his hands is a hunger cue is correct. This is an early sign of hunger, and responding to these cues helps ensure the baby is fed before becoming too upset.
Choice C rationale
Feeding the baby for 10 minutes on each breast may not be adequate. The duration of feeding can vary, and it is important to allow the baby to feed until they are satisfied, which may take longer than 10 minutes.
Choice D rationale
Waking the baby at least every 6 hours at night for feedings is not recommended. Newborns should be fed more frequently, typically every 2-3 hours, including during the night, to ensure they receive enough nutrition.