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.
Free Nursing Test Bank
- Free Pharmacology Quiz 1
- Free Medical-Surgical Quiz 2
- Free Fundamentals Quiz 3
- Free Maternal-Newborn Quiz 4
- Free Anatomy and Physiology Quiz 5
- Free Obstetrics and Pediatrics Quiz 6
- Free Fluid and Electrolytes Quiz 7
- Free Community Health Quiz 8
- Free Promoting Health across the Lifespan Quiz 9
- Free Multidimensional Care Quiz 10
View Related questions
Correct Answer is ["A","B","C"]
Explanation
Choice A rationale
Irregular spotting is common after the placement of an IUD as the body adjusts to the device. This is a normal side effect and typically resolves within a few months.
Choice B rationale
Avoiding tampons initially after IUD placement is advised to prevent displacement or infection. Once the IUD is properly positioned and the risk of infection decreases, tampons can generally be used.
Choice C rationale
Informed consent is required prior to IUD placement to ensure the client understands the procedure, potential risks, and benefits, ensuring an informed decision.
Choice D rationale
IUDs typically need to be replaced every 3 to 10 years, depending on the type. Replacing an IUD every 2 years is not accurate and does not align with standard medical
recommendations.
Correct Answer is D
Explanation
Choice A rationale
Only one dose of rubella immunization is necessary post-delivery, no need for a second dose in 2 weeks.
Choice B rationale
Prevention of pregnancy is recommended for at least 1 month (not 4 months) after receiving the rubella vaccine to avoid possible teratogenic effects.
Choice C rationale
An additional rubella immunization is not recommended during pregnancy as the live vaccine is contraindicated during gestation.
Choice D rationale
Rubella vaccine is safe for breastfeeding mothers, as it does not affect the safety of breast milk.