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The client in labor received an epidural anesthesia 20 minutes ago. The nurse assesses that the client’s BP is 98/62 mm Hg and that the client is lying supine. What should the nurse do next?
- A. Increase the lactated Ringer’s infusion rate.
- B. Elevate the client’s legs for 2 to 3 minutes.
- C. Place the bed in 10- to 20-degree Trendelenburg.
- D. Position the client in a left side-lying position.
Correct Answer: D
Rationale: The first action is to place the client in a left side-lying position. This displaces the uterus and alleviates aortocaval compression. Increasing the infusion rate may be implemented if repositioning the client does not correct the hypotension. Elevating the client’s legs for 2 to 3 minutes is done with severe or prolonged hypertension to increase blood return from the extremities. It may be implemented after repositioning to left side, increasing the IV rate, and placing in Trendelenburg position. Placing in 10- to 20-degree Trendelenburg position is usually implemented if the BP does not increase within 1 to 2 minutes after repositioning to left side and increasing the IV flow rate.
You may also like to solve these questions
The nurse correctly explains that fertilization usually takes place in which structure?
- A. Fallopian tube
- B. Ovary
- C. Uterus
- D. Vagina
Correct Answer: A
Rationale: Fertilization typically occurs in the fallopian tube, where the sperm meets the ovum after ovulation.
Which dietary adjustment is most appropriate for a pregnant teenager?
- A. Increase caloric intake to 2,500 calories per day.
- B. Drink decaffeinated beverages instead of carbonated ones.
- C. Eat foods that are low in carbohydrates and fats.
- D. Choose nonspicy, easy to digest foods.
Correct Answer: A
Rationale: Pregnant teenagers require about 2,500 calories daily to support their growth and the fetus's development.
The postpartum client suffered a fourth-degree perineal laceration during her vaginal birth. Which interventions should the nurse add to the client’s plan of care? Select all that apply.
- A. Limit ambulation to bathroom privileges only.
- B. Decrease fluid intake to 1000 mL every 24 hours.
- C. Instruct the client on a high-fiber diet.
- D. Monitor the uterus for firmness every 2 hours.
- E. Give pm prescribed stool softeners in the am. and at h.s.
Correct Answer: C,E
Rationale: Activity should be increased, not decreased, to reduce the potential for constipation. Fluids should be increased, not decreased, to reduce the potential for dehydration and constipation. The client with a fourth-degree perineal laceration should be instructed to increase dietary fiber to help maintain bowel continence and decrease perineal trauma from constipation. A perineal laceration will not affect the condition of the uterus; there is no need to increase uterine monitoring. The client with a fourth-degree perineal laceration should be given a stool softener bid to help maintain bowel continence and decrease perineal trauma from constipation.
The nurse is caring for the client who has been in the second stage of labor for the last 12 hours. The nurse should monitor for which cardiovascular change that occurs during this stage of labor?
- A. An increase in maternal heart rate
- B. A decrease in the cardiac output
- C. An increase in the white blood cell (WBC) count
- D. A decreased intravascular volume during contractions
Correct Answer: A
Rationale: Maternal HR is normally increased due to pain resulting from increased catecholamine secretion, fear, anxiety, and increased blood volume. When the laboring client holds her breath and pushes against a closed glottis, intrathoracic pressure rises. Blood in the lungs is forced into the left atrium, leading to a transient increase (not decrease) in cardiac output. Although the WBCS increase to 25,000/mm3 to 30,000/mm3 during labor and early postpartum as a physiological response to stress, this is not a cardiovascular change. During the second stage of labor, the maternal intravascular volume is increased (not decreased) by 300 to 500 mL of blood from the contracting uterus.
The client, who delivered a 4200-g baby 4 hours ago, continues to have bright red, heavy vaginal bleeding. The nurse assesses the client’s fundus and finds it to be firm and midway between the symphysis pubis and umbilicus. What should the nurse do next?
- A. Continue to monitor the client’s bleeding and weigh the peripads.
- B. Call the client’s HCP and request an additional visual examination.
- C. Prepare to give oxytocin to stimulate uterine muscle contraction.
- D. Document the findings as normal with no interventions needed at that time.
Correct Answer: B
Rationale: Although the nurse would definitely need to continue to monitor the amount and quality of bleeding, additional intervention is also needed. The nurse should consider the possibility of a vaginal wall or cervical laceration, which could produce heavy, bright red bleeding. The HCP should be notified and asked to perform a visual exam of the vagina to assess for possible lacerations in need of repair. Preparing to administer oxytocin (Pitocin) would be appropriate if the source of bleeding was suspected to be uterine atony, but the uterus is firm and in the expected location. Documenting the findings without further intervention would lead to a failure to identify the source of increased bleeding resulting in possible client injury. Further assessments and interventions are needed.