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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

A temperature of 37.8°C (100°F) 18 hours postpartum is slightly elevated but not necessarily indicative of a serious issue. It may require monitoring but is not the most urgent concern.

Choice B rationale

Abdominal pain during breastfeeding 8 hours postpartum is a common experience due to uterine contractions. While it may cause discomfort, it is not typically an urgent concern.

Choice C rationale

Not having a bowel movement 24 hours postpartum is not uncommon and does not usually require immediate attention. It can be addressed with dietary changes and other interventions.

Choice D rationale

Saturating one perineal pad over 2 hours 6 hours postpartum in a G5P4 client indicates a potential risk of postpartum hemorrhage. This is a more urgent concern that requires immediate assessment and intervention to prevent complications.

Correct Answer is D

Explanation

Choice A rationale

Placing a newborn in the right lateral position is not recommended as it increases the risk of suffocation and sudden infant death syndrome (SIDS)4.

Choice B rationale

Placing a newborn in the left lateral position is also not recommended for the same reasons as the right lateral position.

Choice C rationale

Placing a newborn in the prone position (on their stomach) significantly increases the risk of SIDS and is not recommended.

Choice D rationale

Placing a newborn in the supine position (on their back) is the safest position for sleep and is recommended to reduce the risk of SIDS4.

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