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
Placing the newborn supine and applying pressure to the soles of the feet is not the correct method to elicit the Babinski reflex. This action does not stimulate the appropriate nerve pathways involved in the reflex.
Choice B rationale
Stroking upward on the lateral aspect of the sole of the newborn’s foot is the correct method to elicit the Babinski reflex. This action stimulates the plantar reflex, causing the big toe to extend upward and the other toes to fan out.
Choice C rationale
Pulling the newborn up by the wrist from a supine position is used to elicit the traction response, not the Babinski reflex. The traction response involves the newborn flexing their arms and attempting to lift their head.
Choice D rationale
Touching the corner of the newborn’s mouth elicits the rooting reflex, not the Babinski reflex. The rooting reflex causes the newborn to turn their head toward the stimulus and open their mouth.
Correct Answer is ["D","G","H"]
Explanation
Choice A rationale
Deep tendon reflexes of 1+ are considered within normal limits and do not require immediate follow-up. This finding is not indicative of any acute complications.
Choice B rationale
A blood pressure reading of 136/86 mm Hg is slightly elevated but not critically high. It does not indicate an immediate risk and can be monitored with routine care.
Choice C rationale
A pain rating of 3 on a scale of 0 to 10 is mild and manageable. It does not necessitate immediate follow-up unless there is a sudden and significant increase in pain.
Choice D rationale
A large amount of lochia rubra can be a sign of excessive bleeding and requires immediate follow-up to assess for postpartum hemorrhage. This finding is concerning and needs prompt attention.
Choice E rationale
Peripheral edema of 2+ in bilateral lower extremities is common in the postpartum period due to fluid shifts and should resolve naturally. It does not require immediate follow-up unless it worsens or is accompanied by other symptoms.
Choice F rationale
Soft breasts are normal postpartum when milk has not yet come in or if the client is not breastfeeding. This finding does not require immediate follow-up as it is a normal occurrence.
Choice G rationale
A soft uterine tone can indicate uterine atony, which can lead to hemorrhage. Immediate follow-up is necessary to prevent potential complications such as postpartum hemorrhage.
Choice H rationale
Lateral deviation of the uterus can indicate a displaced uterus, possibly due to a full bladder or other reasons, which requires prompt attention. This finding could lead to complications if not addressed promptly.