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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A rationale

A shrill cry may indicate distress but isn't specifically related to hypoglycemia in newborns.

Choice B rationale

Weak peripheral pulses are more commonly associated with circulatory or cardiac issues rather than hypoglycemia.

Choice C rationale

Yellowish skin suggests jaundice, which is due to elevated bilirubin levels, not hypoglycemia.

Choice D rationale

Hypotonia, or decreased muscle tone, can be a sign of hypoglycemia in newborns, indicating a need to check blood glucose levels.

A. Heart rate 132/min. B. Report of headache. C. Nasal congestion. D. Tremors.

Correct Answer is A

Explanation

Choice A rationale

Terbutaline can cause tachycardia. A heart rate of 132/min is significantly higher than normal and could indicate severe cardiovascular effects.

Choice B rationale

While headaches can occur with terbutaline, they are generally not life-threatening and don't require immediate intervention compared to tachycardia.

Choice C rationale

Nasal congestion is a minor side effect and not a priority compared to a significantly elevated heart rate.

Choice D rationale

Tremors are common with terbutaline use, but they are usually not as concerning as a significantly elevated heart rate.

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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.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a newborn.Which of the following findings indicates a need to check the newborn's blood glucose level for hypoglycemia?

Correct Answer is D

Explanation

A nurse is caring for a client who is at 28 weeks of gestation and has received two doses of terbutaline subcutaneously.Which of the following adverse effects is the priority for the nurse to report to the provider?

Correct Answer is A

Explanation

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