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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 A

Explanation

Choice A rationale

Warm compresses can help alleviate pain and inflammation associated with mastitis. The heat from the compresses increases blood flow to the affected area, promoting healing and reducing discomfort.

Choice B rationale

Wearing a nursing bra can provide support and reduce discomfort for individuals with mastitis. Avoiding a nursing bra may lead to increased pain and discomfort due to lack of support.

Choice C rationale

Limiting oral fluid intake is not recommended for individuals with mastitis. Adequate hydration is essential for overall health and can help maintain milk production, which is important for breastfeeding mothers.

Choice D rationale

Hydrocortisone ointment is not typically recommended for treating mastitis. The primary treatment for mastitis includes antibiotics, pain relief, and supportive measures such as warm compresses and continued breastfeeding.

Correct Answer is D

Explanation

Choice A rationale

Diuresis, or increased urine production, is not a common adverse effect of nalbuphine hydrochloride. This medication is an opioid analgesic used for pain relief during labor.

Choice B rationale

Fever is not a typical adverse effect of nalbuphine hydrochloride. Fever may indicate an infection or other underlying condition that needs to be addressed separately.

Choice C rationale

Diarrhea is not a common adverse effect of nalbuphine hydrochloride. Opioids, including nalbuphine, are more likely to cause constipation rather than diarrhea.

Choice D rationale

Sedation is a known adverse effect of nalbuphine hydrochloride. As an opioid analgesic, it can cause drowsiness and sedation, which is important to monitor in laboring clients to ensure their safety and well-being.

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