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The nurse is monitoring the person's vital signs after the epidural is placed and notices a blood pressure of 80/50 mm Hg. What nursing intervention can be performed prior to the epidural placement to potentially reduce this side effect?
- A. routine use of ephedrine
- B. IV fluid bolus
- C. insertion of indwelling urinary catheter
- D. upright positioning of the laboring person
Correct Answer: B
Rationale: Correct Answer: B - IV fluid bolus
Rationale:
1. IV fluid bolus can help increase blood volume and improve blood pressure.
2. Adequate hydration is crucial before epidural placement to prevent hypotension.
3. Other choices are not directly related to improving blood pressure in this scenario.
Summary:
- A: Routine use of ephedrine is not recommended as a routine prophylactic measure.
- C: Insertion of indwelling urinary catheter is important for monitoring urine output but not for improving blood pressure.
- D: Upright positioning may help prevent hypotension after epidural, but it's not a pre-epidural intervention to address low blood pressure.
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After a forceps-assisted birth, the patient is observed to have continuous bright red lochia and a firm fundus. Which other data would indicate the presence of a potential vaginal wall hematoma?
- A. Lack of an episiotomy
- B. Mild, intermittent perineal pain
- C. Lack of pain in the perineal area
- D. Edema and discoloration of the labia and perineum
Correct Answer: D
Rationale: The correct answer is D. Edema and discoloration of the labia and perineum indicate the presence of a potential vaginal wall hematoma. This is because hematoma can cause swelling and bruising in the affected area. Bright red lochia and a firm fundus are more indicative of postpartum hemorrhage, not vaginal wall hematoma. Choices A and C are not directly related to the presence of a vaginal wall hematoma. Mild, intermittent perineal pain (Choice B) is non-specific and can be present in various postpartum conditions. Thus, option D is the most relevant indicator of a potential vaginal wall hematoma in this scenario.
The nurse detects hypotension in a laboring patient after an epidural. Which actions should the nurse plan to implement? (SeNleUctRaSllIthNatGaTpBpl.y.)C OM
- A. Encourage the patient to drink fluids.
- B. Place the patient in a Trendelenburg position.
- C. Administer a normal saline bolus as prescribe
- D. Administer oxygen at 8 to 10 L/minute per face mask.
Correct Answer: C
Rationale: The correct answer is C: Administer a normal saline bolus as prescribed. In this scenario, hypotension post-epidural could be due to vasodilation leading to decreased blood pressure. Administering a normal saline bolus can help increase intravascular volume and improve blood pressure. Encouraging the patient to drink fluids (A) may not provide immediate volume resuscitation. Placing the patient in a Trendelenburg position (B) can worsen hypotension by increasing pressure on the vena cava. Administering oxygen (D) may be helpful but addressing the hypotension with a saline bolus is the priority.
The best time to teach nonpharmacologic pain control methods to an unprepared laboring patient is during which stage?
- A. Latent phase
- B. Active phase
- C. Second stage
- D. Transition phase
Correct Answer: A
Rationale: The correct answer is A: Latent phase. This stage is ideal for teaching nonpharmacologic pain control methods as the patient is usually more receptive, relaxed, and able to focus. During the latent phase, contractions are typically mild and irregular, allowing the patient to learn and practice techniques effectively. In contrast, the active phase (choice B) is characterized by increased intensity and frequency of contractions, making it challenging for the patient to concentrate on learning. The second stage (choice C) is the pushing stage, where the focus shifts to pushing efforts rather than learning new techniques. The transition phase (choice D) is the most intense stage of labor, making it difficult for the patient to absorb and apply nonpharmacologic pain control methods effectively.
What nursing intervention can be performed prior to epidural placement to potentially reduce a blood pressure drop?
- A. routine use of ephedrine
- B. IV fluid bolus
- C. insertion of indwelling urinary catheter
- D. upright positioning of the laboring person
Correct Answer: B
Rationale: The correct answer is B: IV fluid bolus. Prior to epidural placement, administering an IV fluid bolus can help prevent a drop in blood pressure by increasing preload and maintaining cardiac output. This helps offset the vasodilation effects of the epidural anesthesia. Options A, C, and D are incorrect. Ephedrine (A) is not routinely used before epidural placement due to its potential adverse effects. Insertion of a urinary catheter (C) is not directly related to preventing a blood pressure drop. Upright positioning (D) may actually worsen hypotension by pooling blood in the lower extremities.
When caring for a patient in labor who is considered to be at low risk, which assessments should be included in the plan of care? (Select all that apply.)
- A. Check the DTR each shift.
- B. Monitor and record vital signs frequently during the course of labor.
- C. Document the FHR pattern, noting baseline and response to contraction patterns.
- D. Indicate on the EFM tracing when maternal position changes are don
Correct Answer: B
Rationale: The correct answer is B: Monitor and record vital signs frequently during the course of labor. This is essential to ensure the patient's physiological stability and detect any deviations that may indicate complications. Checking the DTR (Choice A) is not relevant for low-risk patients in labor. Documenting the FHR pattern (Choice C) is important, but not as crucial as monitoring vital signs. Indicating maternal position changes on the EFM tracing (Choice D) is beneficial but not a priority assessment for low-risk patients. Vital sign monitoring is the most critical assessment for ensuring the well-being of the patient in labor.