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,E
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Group B Streptococcus (GBS) colonization in a pregnant client does not typically necessitate a cesarean birth. The primary concern with GBS is the risk of vertical transmission to the neonate during vaginal birth, which can lead to severe neonatal infections like sepsis, meningitis, or pneumonia. Cesarean section is generally reserved for obstetric indications and does not eliminate the risk of GBS transmission if membranes rupture.
Choice B rationale
Intravenous antibiotic prophylaxis is the cornerstone of preventing neonatal GBS disease in colonized mothers. The recommended antibiotics, typically penicillin or ampicillin, are administered during labor once ruptured membranes or active labor commence. This intrapartum treatment significantly reduces bacterial colonization in the birth canal, thereby minimizing the neonate's exposure to the bacteria during passage.
Choice C rationale
A vaginal culture for GBS is typically performed between 36 and 37 weeks of gestation as part of routine prenatal screening. If the client has already been screened and identified as GBS positive at 36 weeks, repeating the culture during active labor is not indicated as the colonization status is already known, and the focus shifts to prophylaxis.
Choice D rationale
Metronidazole is an antibiotic primarily effective against anaerobic bacteria and certain parasites. It is not the drug of choice for Group B Streptococcus prophylaxis. Penicillin or ampicillin are the preferred antibiotics for GBS intrapartum prophylaxis due to their effectiveness against GBS and their favorable safety profile for both the mother and the fetus.
Correct Answer is D
Explanation
Choice A rationale
A negative contraction stress test (CST) indicates that the fetus tolerates uterine contractions well, with no evidence of late decelerations, implying adequate uteroplacental function. Repeating the test in 20 minutes is unnecessary as a negative result signifies fetal well-being and is a favorable outcome.
Choice B rationale
Administering an intravenous fluid bolus is often used in situations like non-reassuring fetal heart rate patterns or to improve uteroplacental perfusion, such as during a non-reactive non-stress test or before an oxytocin challenge. A negative CST indicates a healthy fetus, so a fluid bolus is not indicated.
Choice C rationale
Preparing for a cesarean birth is indicated when there is evidence of fetal distress or a high risk of adverse outcomes, such as with a positive CST (late decelerations present). A negative CST indicates a reassuring fetal status, making a cesarean birth unnecessary based solely on these test results.
Choice D rationale
A negative CST indicates a healthy fetus with good uteroplacental reserve, suggesting that the fetus will likely tolerate the stress of labor. Therefore, allowing the labor to progress naturally is the appropriate action, as there are no indications of fetal compromise.
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