A client who is in the transition phase reports the narcotic pain medication they last received 3 hours ago has worn off.
The client asks if they can have another dose of the narcotic. How should the nurse respond to the request?

"It is too early as the medication should be given only every 4 hours.”.

"I will get permission from your health care provider.”.

"Since it has been over 3 hours, you should be able to have more of the medication.”.

"Your phase of labor makes giving another dose unsafe for the fetus.”

Answer and Explanation

The Correct Answer is D

Choice A rationale

While it is true that many narcotic pain medications are administered every four hours, this response is insufficient and potentially misleading. The duration of action of a narcotic is not the only factor to consider in the context of labor. The client's phase of labor and the potential fetal effects are also critical, particularly in the advanced stages of labor when the fetus is more susceptible to medication-induced respiratory depression.

Choice B rationale

While the nurse may need to consult the healthcare provider, this response is not the most direct or professional answer. The nurse has independent knowledge regarding the safety of medication administration based on the client's stage of labor. In the transition phase, the fetus is at a high risk for respiratory depression if narcotics are administered, and the nurse should explain this rationale directly to the client.

Choice C rationale

This response is incorrect and could be harmful. The time since the last dose is only one factor in medication administration. The transition phase of labor is characterized by rapid cervical dilation and is typically a sign that delivery is imminent. Administering a narcotic at this stage increases the risk of neonatal respiratory depression at birth, as the medication crosses the placenta and affects the fetal central nervous system.

Choice D rationale

The transition phase of labor, typically occurring when the cervix is dilated 8 to 10 cm, is a period of high risk for fetal compromise. Administering a narcotic during this phase is contraindicated because the medication can cross the placental barrier and cause neonatal respiratory depression at the time of delivery. The nurse's response should prioritize fetal safety by explaining this physiological risk, which is the most appropriate and scientific response. .

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Correct Answer is A

Explanation

Choice A rationale

A cesarean section is a major surgical procedure that creates an incision through the abdominal wall and uterus. The most crucial assessment post-operatively is for signs of infection at the incision site. This involves inspecting the site for erythema, warmth, purulent drainage, or dehiscence, which are indicators of surgical site infection. Surgical infections can lead to significant morbidity and mortality, making this assessment paramount.

Choice B rationale

A client's plan to return to work postpartum is an important consideration for discharge planning and psychosocial support. However, it is not a direct physiological or safety assessment in the immediate postpartum period. The priority in the acute recovery phase is to monitor for potential medical complications related to the surgery and childbirth, such as infection, hemorrhage, or thrombosis.

Choice C rationale

While a perineal assessment is necessary after a vaginal delivery, it is not the most important assessment for a client who had a cesarean section. The surgical incision is the primary site of potential complications, such as infection or hemorrhage. The focus should be on the surgical site as it poses the greatest risk for immediate postoperative complications.

Choice D rationale

Breast engorgement, or the filling of breasts with milk, typically occurs between the third and fifth postpartum days. It is a normal physiological process. Assessing for this on the first postpartum day is not a priority. The most critical assessments immediately following a cesarean section involve monitoring for surgical complications, maternal vital signs, and uterine status.

A. "This is not something you should worry about right now". B. "There are no contraindications to a vaginal delivery in the future". C. "Unfortunately you will need a cesarean section for all your future pregnancies". D. "The largest contributing factor to the method of delivery with any future pregnancies is the type of incision the physician performed on your uterus during the surgery".

Correct Answer is D

Explanation

Choice A rationale

This response is dismissive and does not address the patient's concerns. Providing accurate information empowers the patient to make informed decisions about their health. The nurse should always address patient concerns and provide education, especially when it relates to their birth experience and future reproductive health. Failing to do so can erode trust and negatively impact the patient-provider relationship.

Choice B rationale

This statement is an oversimplification and potentially inaccurate. The feasibility of a vaginal birth after a cesarean section (VBAC) depends on several factors, including the type of uterine incision. A classical vertical incision, for instance, is a strong contraindication due to a significantly increased risk of uterine rupture in subsequent pregnancies. The nurse must provide a more nuanced and accurate explanation.

Choice C rationale

This is an incorrect and potentially harmful statement. A previous cesarean section does not automatically preclude a future vaginal delivery. A vaginal birth after cesarean (VBAC) is a viable option for many individuals, particularly those who had a low transverse uterine incision. The decision is based on a careful assessment of risks and benefits with the patient's provider.

Choice D rationale

This statement is the most accurate and scientifically grounded response. The type of uterine incision is the most significant factor determining the safety of a future vaginal delivery. A low transverse incision has a lower risk of rupture during a trial of labor, making VBAC a safe option for many. A classical (vertical) incision, conversely, carries a high risk of uterine rupture, necessitating a repeat cesarean.

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A client who is in the transition phase reports the narcotic pain medication they last received 3 hours ago has worn off. The client asks if they can have another dose of the narcotic. How should the nurse respond to the request?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client who had a cesarean section birth. Which of the following would be the most important assessment to make?

Correct Answer is A

Explanation

Correct Answer is D

Explanation

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A client who is in the transition phase reports the narcotic pain medication they last received 3 hours ago has worn off.
The client asks if they can have another dose of the narcotic. How should the nurse respond to the request?