48. A client, who is gravida 3, para 2, has elected to have epidural anesthesia to relieve labor pain. About 5 minutes after the epidural is placed, a nurse notes the following vital signs: blood pressure is 80/30 mm Hg, pulse is 80, respiration 18, and temperature 99.0°F. Which nursing intervention is most appropriate?
. Place the client in Trendelenburg position.
. Decrease the rate of IV infusion.
. Administer oxygen per nasal cannula.
. Increase the rate of the IV infusion.
Test-Taking Tip
This question is asking for the intervention to resolve the hypotension caused by the epidural. Eliminate the interventions that would not resolve the hypotension. Focus on two options that are opposites of each other (Answer 2, "decrease the rate" and Answer 4, "increase the rate").
Content Area: Maternity, Intrapartum; Integrated Process: Nursing Process, Implementation; Cognitive Level: Analysis; Client Need/Subneed: Physiological Integrity/Reduction of Risk Potential/Vital Signs Changes/Abnormalities
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Answer 1 is incorrect because placing the client in the Trendelenburg position will not resolve her hypotension. The Trendelenburg position provides no benefit for the client to reverse her low blood pressure, and should not be used during pregnancy as a treatment for low blood pressure. Answer 2 is incorrect because decreasing the rate of IV infusion will make the hypotension worse. Decreased intravascular volume may add to the client's hypotension. Answer 3 is incorrect because administering oxygen per nasal cannula will not resolve her hypotension. Hyperoxygenation of the client can increase oxygen perfusion to the fetus, but will do nothing to reverse the woman's low blood pressure. Answer 4 is correct because the appropriate intervention for the client's hypotension is a fluid bolus.