A nurse is administering a 500 mL bolus of lactated Ringer’s for a client who is in labor and has a prescription for spinal anesthesia. Which of the following findings indicates that the IV bolus was effective?
A.
Report of perineal pain as 0 on a scale of 0 to 10.
B.
Increased urinary output.
C.
Blood pressure 110/70 mm Hg.
D.
Report of relief of pruritus.
The correct answer and Explanation is :
The correct answer is C. Blood pressure 110/70 mm Hg.
Explanation:
Lactated Ringer’s (LR) solution is commonly administered as an IV bolus prior to spinal anesthesia in laboring clients to prevent hypotension, a known side effect of spinal or epidural anesthesia. This occurs because spinal anesthesia can cause vasodilation by blocking the sympathetic nervous system, leading to a drop in blood pressure. By administering an IV bolus of isotonic fluid like LR, the nurse increases the intravascular volume, helping to maintain or stabilize blood pressure.
Option C: Blood pressure 110/70 mm Hg indicates that the client’s blood pressure is within a normal range. This suggests that the fluid bolus has been effective in maintaining adequate blood pressure, preventing the typical hypotensive response to spinal anesthesia. Normal blood pressure in an adult typically falls between 90/60 mm Hg and 120/80 mm Hg, so this reading is a positive sign of adequate fluid resuscitation and successful prevention of hypotension.
Why Other Options are Incorrect:
- A. Report of perineal pain as 0 on a scale of 0 to 10: While pain relief can indicate that anesthesia is working, it does not reflect whether the IV bolus was effective. The primary purpose of the bolus is to maintain hemodynamic stability, not manage pain.
- B. Increased urinary output: Though fluid administration can increase urinary output, this is not a reliable indicator of the bolus’s effectiveness in preventing spinal anesthesia-induced hypotension. Urinary output can vary due to other factors like kidney function and hydration status.
- D. Report of relief of pruritus: Pruritus (itching) is a potential side effect of opioid medications sometimes used in combination with spinal anesthesia. Relief of pruritus is unrelated to the effectiveness of the IV bolus in preventing hypotension.
Thus, C is the best answer because maintaining blood pressure is the key goal of administering a bolus prior to spinal anesthesia.