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
A hematoma presents as a localized collection of blood outside the blood vessels, causing a purplish discoloration and swelling, often resulting from trauma during delivery.
Choice B rationale
Retained placental fragments may cause postpartum hemorrhage and infection but would not present as a localized purplish swelling on the perineum.
Choice C rationale
A laceration would involve a tear in the tissue, causing bleeding and pain, but not necessarily a purplish discoloration with localized swelling unless associated with a hematoma.
Choice D rationale
Ecchymosis refers to bruising but is typically a more diffuse discoloration rather than a localized swelling and purplish area as seen with a hematoma.
Correct Answer is D
Explanation
Choice A rationale
Elevating the head of the client’s bed is not indicated in this situation and does not address the issue of excessive bleeding postpartum.
Choice B rationale
Administering terbutaline, a medication used to manage preterm labor, is not relevant in the context of postpartum hemorrhage and excessive bleeding.
Choice C rationale
Initiating oxygen at 2 L/min via nasal cannula may help with oxygenation but does not address the primary issue of excessive postpartum bleeding.
Choice D rationale
Initiating an infusion of oxytocin is the correct action as it helps contract the uterus and reduce postpartum bleeding, making it a crucial step in managing this situation.