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 A
Explanation
Choice A rationale
Rear-facing car seats are safer for infants and toddlers because they provide better support for their head, neck, and spine in the event of a collision. The American Academy of Pediatrics recommends keeping children in rear-facing seats until they are at least 2 years old or until they reach the highest weight or height allowed by the manufacturer.
Choice B rationale
A four-point harness is not sufficient for securing a baby in a car seat. A five-point harness, which includes two shoulder straps, two hip straps, and one crotch strap, provides more secure and effective restraint for infants.
Choice C rationale
The shoulder harness should be positioned in the slots at or below the baby's shoulders, not above, to ensure proper fit and restraint. Placing the harness above the shoulders can result in improper restraint and increased risk of injury in an accident.
Choice D rationale
The correct angle for a rear-facing car seat is typically 45 degrees, not 30 degrees. A 45-degree angle ensures the baby's airway remains open, preventing the head from falling forward and potentially causing breathing difficulties.
Correct Answer is ["A","B"]
Explanation
Choice A rationale
Blood pressure should be assessed as opioid analgesics can cause hypotension, which can be detrimental to both mother and fetus during labor.
Choice B rationale
Fetal heart rate monitoring is essential as opioids can cross the placenta and potentially cause fetal bradycardia or distress, thus necessitating close monitoring.
Choice C rationale
Deep tendon reflexes are not commonly affected by opioid analgesics and therefore are not a primary assessment when administering these medications during labor.
Choice D rationale
Blood glucose levels are not typically influenced by opioid analgesics in the context of labor, so this is not a relevant assessment for this scenario.