A nurse is admitting a female client, age 34, who is at 38 weeks of gestation to the labor and delivery unit for induction of labor.
Which of the following actions should the nurse take prior to implementing the provider’s prescriptions?
Ensure calcium gluconate is readily available.
Obtain the client’s heart rate.
Evaluate the client’s platelet count.
Determine if the client has aspirin sensitivity.
Review the client’s history for documentation of heart disease.
Correct Answer : A,B,D,E
Choice A rationale: Calcium gluconate is the antidote for magnesium sulfate toxicity, often used in labor inductions complicated by preeclampsia or gestational hypertension. Having it readily available ensures prompt treatment of symptoms like respiratory depression or cardiac arrhythmias caused by magnesium overdose. This safety measure is critical because oxytocin use can increase uterine contractions and magnesium sulfate use requires close monitoring to prevent toxicity.
Choice B rationale: Obtaining the client’s heart rate prior to initiating oxytocin is essential to establish a baseline and monitor for tachycardia or bradycardia, which may affect maternal and fetal safety. Oxytocin can cause cardiovascular changes, including hypertension or arrhythmias, especially in clients with gestational hypertension. Continuous maternal cardiac assessment helps detect adverse effects early and adjust treatment accordingly.
Choice C rationale: Evaluating platelet count before induction is important in clients with gestational hypertension due to the risk of HELLP syndrome, which involves thrombocytopenia. Normal platelet levels range from 150,000 to 400,000/mm³; low levels increase bleeding risk during labor and delivery. Knowing platelet status guides safe management decisions, including anesthesia options and readiness for potential hemorrhagic complications.
Choice D rationale: Assessing for aspirin sensitivity is crucial because aspirin is often used in pregnancy for preeclampsia prevention. Aspirin hypersensitivity can lead to allergic reactions or exacerbation of asthma. Since the client has gestational hypertension, determining aspirin tolerance before administering medications is necessary to prevent adverse drug reactions and ensure safe pharmacologic management.
Choice E rationale: Reviewing the client’s history for heart disease documentation is vital as gestational hypertension increases cardiovascular risk. Preexisting heart conditions can complicate labor induction and oxytocin administration due to possible cardiac overload or arrhythmias. A comprehensive cardiac history ensures appropriate monitoring and interventions to prevent maternal and fetal complications during labor.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
A hematocrit of 37% falls within the normal physiological range for a pregnant individual, which typically expands due to increased plasma volume. This hemodilution is a normal adaptive response to pregnancy, ensuring adequate perfusion to the placenta and fetal unit. This finding does not warrant reporting as it reflects a healthy maternal circulatory adjustment.
Choice B rationale
A creatinine level of 0.9 mg/dL is within the normal reference range for renal function in pregnant individuals. Glomerular filtration rate (GFR) increases during pregnancy, leading to a slight decrease in serum creatinine. This value indicates appropriate renal clearance and is not a cause for concern.
Choice C rationale
A WBC count of 11,000/mm³ is generally considered within the physiological elevation often seen during pregnancy, particularly in the second and third trimesters. This mild leukocytosis is an immunological adaptation, supporting the maternal immune response without indicating an infectious process or pathology that requires immediate reporting.
Choice D rationale
A fasting blood glucose of 180 mg/dL is significantly elevated above the normal range (74 to 106 mg/dL) and indicates hyperglycemia. This finding is highly suggestive of gestational diabetes mellitus, which can lead to adverse maternal and fetal outcomes if not managed. Therefore, it requires immediate reporting to the provider for further evaluation and intervention.
Correct Answer is D
Explanation
Choice A rationale
Hydrocodone is an opioid analgesic, but it is typically used for moderate to severe pain and is not commonly administered as a primary agent for severe active labor pain due to its slower onset and potential for more pronounced maternal and neonatal respiratory depression compared to other rapid-acting opioids.
Choice B rationale
Naproxen is a nonsteroidal anti-inflammatory drug (NSAID) primarily used for mild to moderate pain and inflammation. It is generally not effective enough for severe labor pain and is contraindicated in late pregnancy due to potential adverse effects on fetal circulation, such as premature closure of the ductus arteriosus.
Choice C rationale
Naloxone hydrochloride is an opioid antagonist used to reverse opioid-induced respiratory depression. Administering naloxone during active labor would reverse the effects of any pain medication given, exacerbating the client's pain and potentially precipitating opioid withdrawal symptoms, thus it is not an appropriate pain management strategy.
Choice D rationale
Fentanyl citrate is a potent, rapid-acting synthetic opioid analgesic commonly used for severe pain during active labor. Its quick onset and short duration of action make it suitable for intermittent administration, allowing for effective pain relief with a lower risk of prolonged neonatal respiratory depression compared to longer-acting opioids.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.