The nurse is discussing the pros and cons of IV opioid administration during active labor with a client.
Which statement by the client indicates a need for further education?
“Once I receive the medication, I have to stay in bed until I deliver.”
“The variability of my baby’s heart rate could be affected.”
“If I deliver quickly after receiving the medication, my baby may have breathing issues.”
“The medication will not decrease my contraction frequency.”
The Correct Answer is A
Choice A rationale:
Restriction of movement is not a necessary requirement following IV opioid administration during labor. While some healthcare providers may encourage laboring individuals to rest after receiving pain medication, it is not mandatory to remain in bed.
In fact, remaining upright and mobile can often be beneficial during labor. Movement can help encourage fetal descent, improve circulation, and potentially even shorten labor duration.
It's essential to educate clients about the benefits of staying active during labor, even after receiving pain medication. This can empower them to make informed choices about their comfort and positioning during the birthing process.
Choice B rationale:
This statement is accurate. IV opioids can cross the placenta and potentially affect the fetal heart rate.
It's crucial for clients to be aware of this potential effect so that they can understand the importance of fetal monitoring during labor. Healthcare providers will closely monitor the baby's heart rate to ensure it remains within a normal range.
Choice C rationale:
This statement is also accurate. If a baby is born too soon after the mother receives IV opioids, there is a risk of respiratory depression.
This is because the opioids can cross the placenta and affect the baby's breathing. Healthcare providers are trained to manage this risk and will take appropriate measures to ensure the baby's well-being, such as providing respiratory support if needed.
Choice D rationale:
This statement is correct. IV opioids are primarily used to relieve pain during labor, not to decrease the frequency of contractions.
While they may have some mild effects on contraction strength or duration, their primary purpose is to provide pain relief. It's important for clients to understand this distinction so that they have realistic expectations about the medication's effects.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
A positive contraction stress test (CST) indicates a potential problem with the fetal heart's response to uterine contractions, not spontaneous accelerations.
It's not consistent with the findings in this scenario.
Choice C rationale:
A negative CST would show no late decelerations in response to contractions, but it's not relevant here because contractions weren't induced.
Choice D rationale:
A non-reactive NST lacks the required accelerations, which are present in this case.
Choice B rationale:
Definition of reactive NST: A reactive NST is a reassuring fetal heart test that demonstrates a healthy fetal heart rate response to fetal movement. It's characterized by two or more fetal heart rate accelerations of at least 15 beats per minute (bpm) lasting at least 15 seconds within a 20-minute period.
Significance of the findings: The presence of three accelerations measuring 15 bpm by 15 seconds within 20 minutes meets the criteria for a reactive NST. This suggests that the fetal nervous system is functioning well and responding appropriately to stimuli, indicating a healthy fetal heart rate pattern.
Nurse's reporting: The nurse should accurately report this finding to the provider as a "reactive nonstress test (NST)." This information is crucial for clinical decision-making regarding the ongoing management of the pregnancy.
Correct Answer is C
Explanation
Choice A rationale:
Drug/alcohol use: While substance abuse during pregnancy can lead to adverse outcomes such as preterm labor, fetal growth restriction, and birth defects, it is not considered a primary factor in determining high-risk status for this patient. The specific substances involved (cocaine and alcohol) are indeed associated with risks, but they are not as significant as other factors in this case.
Age: The patient's age of 24 is not considered a high-risk factor for pregnancy. Advanced maternal age (typically defined as 35 years or older) is associated with increased risks for chromosomal abnormalities and other complications, but this patient falls below that age threshold.
Family history: Family history of diabetes mellitus, cancer, and neural tube defects can be relevant to pregnancy risk, but in this case, other factors outweigh their significance.
Choice B rationale:
Blood pressure: The patient's blood pressure of 108/70 mm Hg is within the normal range and does not contribute to highrisk categorization. High blood pressure (hypertension) during pregnancy can lead to preeclampsia and other complications, but this patient does not present with hypertension.
Age: As explained in Choice A, the patient's age is not a high-risk factor.
BMI: A BMI of 17 is considered underweight, which can increase the risk of certain pregnancy complications such as preterm birth and low birth weight. However, in this case, other factors are more significant in determining high-risk status.
Choice C rationale:
Family history: The patient's family history of a neural tube defect (NTD) in a close relative is a significant risk factor for NTDs in her own pregnancy. NTDs are serious birth defects that affect the brain and spinal cord, and they can have lifelong implications for the child. This factor alone warrants a high-risk categorization.
BMI: The patient's underweight BMI of 17 further contributes to her high-risk status, as it can increase the likelihood of certain complications as mentioned earlier.
Drug/alcohol abuse: The patient's admission of cocaine and alcohol use, even if occasional, is a concerning factor for pregnancy. Cocaine, in particular, is a potent vasoconstrictor that can negatively impact fetal growth and development. Alcohol consumption during pregnancy can lead to fetal alcohol spectrum disorders (FASDs), which can cause a range of physical, cognitive, and behavioral problems.
Choice D rationale:
Age: As explained previously, the patient's age is not a high-risk factor.
BMI: The patient's BMI is a contributing factor, but not the most significant one in this case.
Family history: The patient's family history is relevant, but the presence of a neural tube defect in a close relative is the most significant aspect of her family history in terms of pregnancy risk.
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