A nurse is preparing to administer an opioid analgesic to a client who is in active labor.Which of the following assessments should the nurse perform? (Select all that apply.)
Blood pressure.
Fetal heart rate.
Deep tendon reflexes.
Blood glucose.
Correct Answer : A,B
Choice A rationale
Blood pressure should be assessed as opioid analgesics can cause hypotension, which can be detrimental to both mother and fetus during labor.
Choice B rationale
Fetal heart rate monitoring is essential as opioids can cross the placenta and potentially cause fetal bradycardia or distress, thus necessitating close monitoring.
Choice C rationale
Deep tendon reflexes are not commonly affected by opioid analgesics and therefore are not a primary assessment when administering these medications during labor.
Choice D rationale
Blood glucose levels are not typically influenced by opioid analgesics in the context of labor, so this is not a relevant assessment for this scenario.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Holding the newborn during the initial visit may make the older sibling feel left out or jealous. Encouraging involvement with the new baby may be more beneficial.
Choice B rationale
Spending individual time with the older sibling helps them feel valued and ensures they do not feel neglected, facilitating better acceptance of the newborn.
Choice C rationale
Having the older sibling purchase a gift for the newborn can create a positive association, but it is less impactful than ensuring individual time and attention.
Choice D rationale
Postponing the introduction until discharge can increase feelings of jealousy or resentment, as the older sibling might feel excluded from the new family dynamic during a crucial time.
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"},"F":{"answers":"B"},"G":{"answers":"A"}}
Explanation
- Administration of IV fluids: This is anticipated as it ensures the client remains well-hydrated, which is important for both maternal and fetal health.
- Continuous monitoring of FHR: This is anticipated to monitor the fetal well-being and ensure there are no signs of fetal distress.
- Abdominal ultrasound: This is anticipated to assess fetal growth, amniotic fluid levels, and placental positioning.
- Digital cervical exam to assess dilation and effacement: This is contraindicated because frequent cervical exams can increase the risk of infection and may cause unnecessary discomfort, especially if there are no signs of labor.
- Laboratory testing: CBC, Blood Type & Rh, Coagulation Studies: These tests are anticipated to provide important information about the client's blood count, blood type, Rh status, and coagulation parameters, which are crucial for managing potential complications.
- Placement of an internal fetal spiral electrode: This is contraindicated as it is an invasive procedure that carries risks, and it is unnecessary given that the FHR is within normal limits with external monitoring.
- Administration of betamethasone: This is anticipated as betamethasone is often given to promote fetal lung maturity in cases where there is a risk of preterm birth.
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.