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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

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.

Correct Answer is B

Explanation

Choice A rationale

During labor, the body experiences physiological stress, which typically causes an increase, not a decrease, in white blood cell (WBC) count. This increase is a normal response to stress.

Choice B rationale

Blood glucose levels can decrease during labor due to the energy expenditure and physiological demands of the process. This is why it is important to monitor glucose levels and provide necessary interventions if hypoglycemia occurs.

Choice C rationale

The respiratory rate generally increases during labor to meet the increased oxygen demands of the body. A decrease in respiratory rate is not expected during this time.

Choice D rationale

Body temperature may increase slightly during labor due to the physical exertion and metabolic activity involved. A decrease in temperature is not a typical finding during labor.

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