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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

Serum bilirubin is not the priority test for hyperemesis gravidarum. It is more relevant for assessing liver function and jaundice.

Choice B rationale

Liver enzymes may be elevated in hyperemesis gravidarum, but they are not the priority test. The primary concern is dehydration and electrolyte imbalance.

Choice C rationale

A CBC can provide information on the client’s overall health, but it is not the priority test for hyperemesis gravidarum. The focus should be on assessing hydration status.

Choice D rationale

Urinalysis for ketones is the priority test because it helps assess the severity of dehydration and malnutrition. The presence of ketones indicates that the body is breaking down fat for energy, which is a sign of inadequate caloric intake.

Correct Answer is B

Explanation

Choice A rationale

Acrocyanosis is a common finding in newborns and is not a sign of dehydration. It usually resolves on its own.

Choice B rationale

A capillary refill time greater than 3 seconds can indicate dehydration in a newborn. It suggests poor perfusion and fluid status.

Choice C rationale

Voiding four times in the past 24 hours is within the normal range for a newborn and does not indicate dehydration.

Choice D rationale

A flat soft anterior fontanel is normal in newborns and does not indicate dehydration. A sunken fontanel would be a sign of dehydration.

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