A nurse is assessing a client who is at 33 weeks of gestation.
Which of the following findings should the nurse report to the provider?

Choice A rationale

Fetal heart rate assessment is paramount before administering an opioid analgesic during labor. Opioids can cross the placental barrier and cause central nervous system depression in the fetus, potentially leading to decreased fetal heart rate variability or transient decelerations. Therefore, a baseline and ongoing fetal heart rate monitoring is essential to ensure fetal well-being.

Choice B rationale

Deep tendon reflexes are primarily assessed when administering magnesium sulfate for preeclampsia, not typically before opioid analgesics. Magnesium sulfate can cause central nervous system depression and affect neuromuscular transmission, necessitating regular monitoring of deep tendon reflexes to assess for signs of toxicity. Opioids do not directly affect reflex activity in the same manner.

Choice C rationale

Blood glucose levels are not a standard assessment before administering opioid analgesics during labor. Blood glucose monitoring is crucial for clients with diabetes or gestational diabetes, or those receiving intravenous dextrose, but it is not directly related to opioid administration and its immediate effects on the mother or fetus.

Choice D rationale

Blood pressure assessment is crucial before administering an opioid analgesic because these medications can cause maternal hypotension due to their vasodilatory effects. Hypotension can reduce placental perfusion, compromising fetal oxygenation. Establishing a baseline blood pressure and monitoring it closely after administration helps ensure maternal cardiovascular stability and fetal well-being.

Choice E rationale

Pain level assessment is fundamental before administering an opioid analgesic. The primary purpose of administering an opioid is to alleviate labor pain. A thorough assessment of the intensity, location, and character of pain guides the choice, dosage, and timing of the analgesic, ensuring effective pain management and patient comfort while minimizing unnecessary medication.

Complete the sentence: The nurse should massage the uterus and prepare to administer oxytocin.

Rationale for correct answers:
Uterine atony is the most common cause of postpartum hemorrhage (PPH), indicated by a boggy uterus and heavy bleeding with clots. Uterine massage stimulates uterine contractions, promoting involution and reducing bleeding. Oxytocin is a first-line uterotonic agent that increases uterine tone by stimulating smooth muscle contraction, helping to control hemorrhage. Normal hemoglobin is 11-16 g/dL; the client’s drop to 9.4 g/dL and hematocrit decrease to 27% (normal 33%-47%) indicate blood loss requiring prompt intervention.

Rationale for incorrect Response 1 options:
Inserting an indwelling urinary catheter is unnecessary here because the client emptied her bladder without difficulty, and urinary retention is not evident. Oxygen administration by nasal cannula is not indicated since the client’s respiratory rate is normal and there is no sign of hypoxia. Immediate oxygen is reserved for hypoxic or unstable patients.

Rationale for incorrect Response 2 options:
Administering oxygen by nasal cannula is not needed without hypoxia signs. Initiating a 1000 mL sodium chloride bolus might be considered later if hypovolemia or hypotension worsens but is not the immediate priority. Inserting an indwelling urinary catheter is not indicated as the bladder is emptying normally, and unnecessary catheterization risks infection.

Take-home points:

• Postpartum hemorrhage is primarily caused by uterine atony, presenting with a boggy uterus and heavy bleeding.
• Prompt uterine massage and administration of oxytocin are critical first-line interventions to control bleeding.
• Laboratory values such as hemoglobin and hematocrit help assess blood loss severity and guide management.
• Differentiation from other causes of bleeding (e.g., retained placenta, lacerations) requires assessment but initial treatment focuses on uterine tone restoration.