A nurse is caring for a client who is in labor and has received an epidural. Which of the following actions should the nurse take?
Explanation & Rationale
A. Reposition the client sideways each hour: Repositioning helps prevent pressure injuries, promotes even distribution of the anesthetic, and reduces the risk of unilateral block or venous stasis, which is especially important after epidural placement. B. Have protamine sulfate available at the bedside: Protamine sulfate is an antidote for heparin, not epidural anesthesia. It has no role in managing side effects or complications related to an epidural. C. Monitor the client for hypertension: Epidural anesthesia commonly causes hypotension due to vasodilation. The nurse should monitor for low blood pressure, not elevated readings. D. Decrease the maintenance infusion rate of IV fluid: IV fluids are often increased prior to and after epidural placement to counteract potential hypotension. Reducing the rate could worsen the risk of low blood pressure.