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?
Fetal heart rate.
Deep tendon reflexes.
Blood glucose.
Blood pressure.
Pain level.
Correct Answer : A,D,E
Administering opioid analgesics during active labor requires applying knowledge of pharmacology and maternal-fetal monitoring. The nurse must prioritize assessments that identify potential respiratory depression, cardiovascular changes, and the effectiveness of the medication while ensuring the safety of the fetus, which is sensitive to drug-induced changes.
Choice A rationale: Opioids cross the placental barrier and can cause decreased fetal heart rate variability or neonatal respiratory depression. Assessing the fetal heart rate before administration is critical to ensure the fetus is stable and not already experiencing distress that could be exacerbated.
Choice B rationale: Deep tendon reflexes are primarily assessed to monitor for magnesium sulfate toxicity or preeclampsia complications. Opioid analgesics do not typically affect these reflexes, making this assessment a lower priority compared to respiratory and cardiovascular monitoring during the active stage of labor.
Choice C rationale: Blood glucose monitoring is essential for clients with gestational diabetes but is not a standard requirement for administering opioid analgesics. The medication does not directly impact glucose homeostasis, so this assessment is not mandatory for the specific goal of pain management.
Choice D rationale: Opioids can cause maternal hypotension and respiratory depression due to their effect on the central nervous system. Monitoring blood pressure ensures the mother maintains adequate perfusion to the placenta, which is vital for the health and oxygenation of the fetus.
Choice E rationale: Assessing the pain level on a scale of 0 to 10 is necessary to establish a baseline and determine the need for medication. Post-administration assessment allows the nurse to evaluate the efficacy of the analgesic and the mother’s tolerance.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
While weight gain is crucial during pregnancy, a blanket statement of 2 pounds per week is not universally appropriate. The recommended rate of weight gain varies based on the client's pre-pregnancy BMI and the trimester. Excessive or insufficient weight gain can lead to adverse maternal and fetal outcomes, including macrosomia or intrauterine growth restriction, highlighting the need for individualized nutritional guidance rather than a fixed weekly gain.
Choice B rationale
Dieting during pregnancy, especially restrictive calorie intake, can significantly compromise the nutrient supply to the developing fetus. Fetal growth and organogenesis are highly dependent on adequate maternal nutritional stores and daily nutrient intake. Inadequate nutrition can lead to low birth weight, premature birth, and long-term health complications for the infant, emphasizing the dangers of unguided dietary restrictions.
Choice C rationale
A dietitian possesses specialized knowledge in medical nutrition therapy and can provide personalized recommendations based on the adolescent's specific nutritional needs, gestational age, and pre-pregnancy weight. This collaborative approach ensures optimal maternal and fetal health by addressing any deficiencies, managing appropriate weight gain, and promoting healthy eating habits throughout the pregnancy, which is crucial for adolescent development and pregnancy outcomes.
Choice D rationale
The caloric needs of a pregnant adolescent increase in the second and third trimesters, but a fixed additional 700 calories per day may not be accurate for all individuals. Caloric requirements are dynamic and depend on pre-pregnancy weight, activity level, and the specific stage of gestation. Overestimation can lead to excessive weight gain, while underestimation can result in inadequate fetal growth, necessitating individualized assessment.
Correct Answer is D
Explanation
Choice A rationale
Relying solely on facial recognition of staff members is an insufficient and potentially dangerous security measure. Hospital staff members can change shifts, and imposters might attempt to abduct newborns. Robust security protocols, such as mandatory identification badges and alarm systems on infant security tags, are designed to prevent unauthorized individuals from leaving the unit with an infant, providing a more reliable defense against abduction.
Choice B rationale
The instruction to remove a newborn's microchip identification band after arriving home is inaccurate and potentially misleading. Hospitals typically use infant security tags or bands that are removed by staff upon discharge, not by the parents at home. These bands are crucial for preventing abductions within the facility by triggering alarms if an infant is taken beyond designated boundaries.
Choice C rationale
Personally carrying a newborn to the nursery, especially without supervision or adherence to facility protocols, increases the risk of abduction. Hospitals often require staff to transport infants in bassinets or cribs, typically with two staff members present, to minimize opportunities for unauthorized individuals to gain access to or abduct a newborn. This procedure enhances infant safety significantly.
Choice D rationale
Bringing the newborn in the bassinet into the bathroom with the mother maintains constant direct observation and reduces the risk of abduction. This strategy minimizes the time the infant is left unattended, preventing opportunities for an abductor to seize the child. Maintaining proximity and direct line of sight is a fundamental principle of infant security in a hospital environment.
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.