A nurse is caring for a client who is in active labor. The nurse administers butorphanol IV bolus for pain. Which of the following findings should the nurse report to the provider following this medication?

Blood pressure 136/88 mm Hg.

Moderate fetal heart rate variability.

Respiratory rate 100/min.

Urinary output 120 mL in 2 hr.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

Blood pressure of 136/88 mm Hg should be monitored, but it is not a finding that the nurse needs to urgently report to the provider following the administration of butorphanol. The blood pressure reading is slightly elevated but might be attributed to pain or anxiety during labor.

Choice B rationale:

Moderate fetal heart rate variability is a reassuring sign of fetal well-being and is an expected finding during labor. It does not require immediate reporting to the provider.

Choice C rationale:

Respiratory rate of 100/min is significantly increased and should be reported to the provider following the administration of butorphanol. Respiratory depression is a potential side effect of opioids like butorphanol, and a respiratory rate of 100/min raises concern for potential respiratory compromise.

Choice D rationale:

Urinary output of 120 mL in 2 hours is an acceptable finding during labor and does not require immediate reporting to the provider. Adequate urinary output varies, but generally, 30 mL/hour is considered acceptable during labor.

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Correct Answer is C

Explanation

Choice A rationale:

The nurse should not include the information about beginning Kegel exercises 6 to 7 weeks after delivery because Kegel exercises are pelvic floor exercises that help improve bladder control and should be started earlier, immediately after childbirth. Delaying the exercises for 6 to 7 weeks could result in weaker pelvic floor muscles and potentially exacerbate postpartum urinary issues.

Choice B rationale:

The nurse should not include the information that the client doesn't need to use birth control if exclusively breastfeeding. While exclusive breastfeeding can provide some natural contraceptive effect, it is not a reliable method, and there is still a risk of pregnancy during the postpartum period. The nurse should advise the client to use appropriate birth control methods to prevent unintended pregnancies.

Choice C rationale:

This is the correct answer. The nurse should include information about the client's breasts becoming firm and tender 3 to 5 days after delivery. This is a normal physiological response known as engorgement, which occurs as the breasts prepare for breastfeeding.

Choice D rationale:

The nurse should not inform the client that her bleeding will remain bright red for the next 6 to 8 weeks. While some postpartum bleeding is normal (known as lochia), the color and amount of bleeding change over time. Initially, it is bright red and gradually transitions to a lighter color over the following weeks.

A. Intense contractions lasting 45 to 60 seconds. B. Progressive sacral discomfort during contractions. C. A sense of excitement and warm, flushed skin. D. An urge to have a bowel movement during contractions.

Correct Answer is D

Explanation

Choice A rationale:

Intense contractions lasting 45 to 60 seconds are normal during labour and indicate effective uterine activity. This finding does not warrant immediate reassessment.

Choice B rationale:

Progressive sacral discomfort during contractions can be a normal part of labour as the baby descends into the birth canal. It does not necessarily indicate a need for reassessment.

Choice C rationale:

A sense of excitement and warm, flushed skin can be a common emotional and physiological response during labour, particularly as the woman reaches the final stages of delivery. This finding does not necessarily require immediate reassessment.

Choice D rationale:

"An urge to have a bowel movement during contractions”. is the correct answer because it could be an indication that the client is experiencing the urge to push, which means the baby's head is descending and nearing delivery. The nurse should reassess the client promptly to determine if she is fully dilated and ready to push.

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A nurse is caring for a client who is in active labor. The nurse administers butorphanol IV bolus for pain. Which of the following findings should the nurse report to the provider following this medication?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing teaching to a client about postpartum care. Which of the following information should the nurse include?

Correct Answer is C

Explanation

A nurse is caring for a client who is in labour. Which of the following findings should prompt the nurse to reassess the client?

Correct Answer is D

Explanation

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