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
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.
Correct Answer is A
Explanation
Choice A rationale
Warming the newborn’s heel for 5 to 10 minutes before the puncture increases blood flow, making it easier to collect a blood sample.
Choice B rationale
The outer aspect of the heel is the recommended site for puncture to avoid injury to the bone and nerves.
Choice C rationale
Leaving the heel open to the air after the puncture is not recommended as it can increase the risk of infection.
Choice D rationale
Applying an antiseptic after collecting the specimen is not necessary and can interfere with the blood sample.