Exhibits

Here are the questions from the mix up well completed.

The nurse is assisting with planning care for the client. After review of the client's electronic medical record (EMR), which of the following interventions should the nurse recommend as anticipated, nonessential, or contraindicated?

Choice A rationale

A nonstress test (NST) is a non-invasive prenatal test that monitors the fetal heart rate (FHR) in response to fetal movement. Accelerations of the FHR (increase of ≥ 15 beats per minute lasting ≥ 15 seconds) with movement over 20 minutes (reactive NST) indicate an intact fetal central nervous system and well-oxygenated fetus.

Choice B rationale

A typical NST usually takes about 20 to 40 minutes to complete. A prolonged duration of 2 to 4 hours is usually not necessary unless the fetus is initially inactive, requiring stimulation or extended monitoring to obtain a conclusive tracing. This duration suggests a misunderstanding of the expected procedure length.

Choice C rationale

An NST is generally performed for pregnancies deemed high-risk (e.g., post-dates, diabetes, hypertension, decreased fetal movement), not simply because it is the client's first pregnancy (primigravida). This statement indicates a misconception about the clinical indication for undergoing this specific fetal surveillance test.

Choice D rationale

The primary purpose of an NST is to assess fetal heart rate reactivity; it does not measure the strength or intensity of uterine contractions. Uterine contractions are measured by the tocodynamometer but their strength would be assessed using an internal uterine pressure catheter, which is not part of the standard NST procedure.

Choice A rationale

A BP of 105/62 mm Hg is within the expected normal range for a postpartum adolescent client. A typical normotensive range is 90-140 mm Hg systolic and 60-90 mm Hg diastolic. Opioids like morphine can cause mild hypotension, but this reading doesn't indicate an immediate, life-threatening crisis.

Choice B rationale

A respiratory rate of 11/min is the priority because it signifies respiratory depression, a life-threatening, dose-related adverse effect of opioid analgesics like morphine. The normal respiratory rate for an adolescent is 12-20 breaths/min. Rates ≤ 12/min require immediate intervention, including potential administration of an opioid antagonist like naloxone.

Choice C rationale

Urinary retention is a common side effect of opioid administration due to increased bladder sphincter tone and reduced detrusor muscle contractility. While uncomfortable and potentially leading to urinary tract infection or bladder damage, it is less acute and life-threatening than respiratory depression.

Choice D rationale

Blurred vision can be an uncommon side effect of morphine, possibly due to miosis (pupil constriction) or minor changes in intraocular pressure. This finding requires further assessment but is a non-life-threatening adverse effect and does not pose the immediate threat of respiratory depression.