If the fetal monitor demonstrates the following pattern, which action would the nurse perform first? (Click on paperclip if image is not showing).

Choice A rationale

While it is true that many narcotic pain medications are administered every four hours, this response is insufficient and potentially misleading. The duration of action of a narcotic is not the only factor to consider in the context of labor. The client's phase of labor and the potential fetal effects are also critical, particularly in the advanced stages of labor when the fetus is more susceptible to medication-induced respiratory depression.

Choice B rationale

While the nurse may need to consult the healthcare provider, this response is not the most direct or professional answer. The nurse has independent knowledge regarding the safety of medication administration based on the client's stage of labor. In the transition phase, the fetus is at a high risk for respiratory depression if narcotics are administered, and the nurse should explain this rationale directly to the client.

Choice C rationale

This response is incorrect and could be harmful. The time since the last dose is only one factor in medication administration. The transition phase of labor is characterized by rapid cervical dilation and is typically a sign that delivery is imminent. Administering a narcotic at this stage increases the risk of neonatal respiratory depression at birth, as the medication crosses the placenta and affects the fetal central nervous system.

Choice D rationale

The transition phase of labor, typically occurring when the cervix is dilated 8 to 10 cm, is a period of high risk for fetal compromise. Administering a narcotic during this phase is contraindicated because the medication can cross the placental barrier and cause neonatal respiratory depression at the time of delivery. The nurse's response should prioritize fetal safety by explaining this physiological risk, which is the most appropriate and scientific response. .

Choice A rationale

Administering an iron supplement daily is contraindicated unless the child has a diagnosed iron deficiency. Sickle cell anemia is characterized by a hemolytic process, where red blood cells are destroyed prematurely. This leads to a higher-than-normal iron level in the body, as the iron from the destroyed cells is released. Unnecessary iron supplementation can lead to iron overload, which can be toxic to the body.

Choice B rationale

Encouraging long-distance running is not advised for a child with sickle cell anemia. Strenuous physical activity can lead to dehydration and hypoxemia, which are major triggers for a sickle cell crisis. The increased metabolic demand on the body during such activities can promote sickling of red blood cells, leading to vaso-occlusion and severe pain.

Choice C rationale

Limiting the child's fluid intake is a dangerous practice. Dehydration is a major trigger for sickling of red blood cells. When the body is dehydrated, the blood becomes more concentrated, and the red blood cells are more likely to deform into the characteristic sickle shape. Adequate hydration is essential to maintain blood volume and prevent a crisis.

Choice D rationale

An upper respiratory infection can be a trigger for a sickle cell crisis. Infections, especially those that cause fever, increase the body's metabolic rate and can lead to dehydration and acidosis. These physiological changes promote the sickling of red blood cells, which can block blood vessels and cause a painful crisis. Prompt medical attention is crucial to manage the infection and prevent a crisis.