A nurse is caring for a client who is in active labor and is scheduled to receive epidural anesthesia.
Which of the following actions should the nurse take?
Monitor blood pressure every 30 minutes following epidural placement.
Administer lactated Ringer's 500 mL bolus via intermittent IV infusion prior to epidural placement.
Administer oxygen via nasal cannula at 2 L/min prior to epidural placement.
Reposition the client every hour following epidural placement.
The Correct Answer is B
Choice A rationale
Monitoring blood pressure every 30 minutes following epidural placement is important but not the initial action. Epidural anesthesia can lead to a sudden drop in blood pressure, so
frequent monitoring is crucial. However, the initial step should focus on preventing hypotension.
Choice B rationale
Administering lactated Ringer's 500 mL bolus via intermittent IV infusion prior to epidural placement helps in maintaining blood pressure. Epidural anesthesia can cause vasodilation,
leading to hypotension. Preloading with fluids ensures adequate blood volume and reduces the risk of a significant drop in blood pressure.
Choice C rationale
Administering oxygen via nasal cannula at 2 L/min prior to epidural placement is not necessary unless the client has respiratory complications. Oxygen supplementation is used to
treat or prevent hypoxia, which is not a primary concern in this scenario.
Choice D rationale
Repositioning the client every hour following epidural placement is important to ensure even distribution of the anesthetic and prevent pressure sores. However, this is not the initial
action to take for preventing hypotension.
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Correct Answer is D
Explanation
Choice A rationale
Taking iron supplements with milk is not advised because calcium in milk can interfere with the absorption of iron, reducing its effectiveness.
Choice B rationale
Doubling the dose of iron supplements if a dose is missed is not recommended because it can cause gastrointestinal issues and toxicity. It's better to just continue with the regular
dosing schedule.
Choice C rationale
Consuming 29 grams of fiber daily is a good practice for overall health, but it does not directly aid in iron absorption. Fiber can actually bind to iron and decrease its absorption in the
intestines.
Choice D rationale
Vitamin C enhances the absorption of non-heme iron (found in supplements) by converting it into a more absorbable form. Taking vitamin C with iron supplements increases their
effectiveness, making this statement correct.
Correct Answer is C
Explanation
Choice A rationale
Giving glucose water after feedings is not recommended for newborns undergoing phototherapy. Breastfeeding or formula feeding should be continued to provide adequate nutrition and hydration.
Choice B rationale
Instructing the client to avoid breastfeeding during treatment is not necessary. Breastfeeding should continue to promote bonding, provide nutrition, and help with the infant's hydration and bilirubin excretion.
Choice C rationale
Monitoring intake and output is crucial for a newborn receiving phototherapy to ensure proper hydration and assess the effectiveness of the treatment in lowering bilirubin levels.
Choice D rationale
Applying lotions and ointments throughout the treatment is not recommended, as they can interfere with the effectiveness of phototherapy. The skin should be clean and dry to maximize exposure to the phototherapy light.