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 B
Explanation
Choice A rationale
Meconium stools are common in newborns and not a concern in the context of weight loss.
Choice B rationale
Depressed fontanels can indicate dehydration in a newborn, which is critical, especially with significant weight loss.
Choice C rationale
Rust-stained urine is often due to urate crystals and is typical in newborns, not specifically alarming.
Choice D rationale
Overlapping suture lines can be a normal finding in a newborn's head and not indicative of an acute problem relating to weight loss.
Correct Answer is A
Explanation
Choice A rationale
Fetal heart rate (FHR) accelerations with fetal movement are a sign of a healthy and reactive nonstress test. This indicates that the fetus is well-oxygenated and there is no immediate distress.
Choice B rationale
Late decelerations of the FHR occur with contractions and are a concern for fetal hypoxia. This does not indicate a reactive nonstress test and instead suggests the need for further evaluation.
Choice C rationale
Variable decelerations are abrupt decreases in FHR and could indicate umbilical cord compression. This does not correlate with a reactive nonstress test.
Choice D rationale
FHR pattern with minimal variability can be a sign of fetal distress or compromised oxygenation. It is not indicative of a reactive nonstress test.