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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?

A.

Monitor blood pressure every 30 minutes following epidural placement.

B.

Administer lactated Ringer's 500 mL bolus via intermittent IV infusion prior to epidural placement.

C.

Administer oxygen via nasal cannula at 2 L/min prior to epidural placement.

D.

Reposition the client every hour following epidural placement.

Answer and Explanation

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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View Related questions

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.

Correct Answer is D

Explanation

Choice A rationale

Transient circumoral cyanosis is common in newborns, especially when crying or feeding, and usually resolves on its own without intervention.

Choice B rationale

Transient strabismus, or the temporary crossing of the eyes, is normal in newborns due to underdeveloped eye muscles and usually resolves as the infant grows.

Choice C rationale

Caput succedaneum is the swelling of the scalp caused by pressure during delivery. It is usually benign and resolves within a few days without treatment.

Choice D rationale

Generalized petechiae, or small red or purple spots on the skin, can indicate a serious underlying condition such as a clotting disorder or infection and requires immediate medical evaluation.

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