When is it most important for the nurse to assess a pregnant client's deep tendon reflexes (DTRs)?
When the client has ankle edema.
If the client has an elevated blood pressure.
During admission to labor and delivery.
Within the first trimester of pregnancy.
The Correct Answer is B
Choice A reason: When the client has ankle edema, it is important for the nurse to assess for other signs of fluid retention, such as weight gain, jugular venous distension, and crackles in the lungs. However, ankle edema alone is not a specific indicator of preeclampsia or eclampsia, which are conditions that can cause hyperreflexia or increased DTRs.
Choice C reason: During admission to labor and delivery, it is important for the nurse to assess various aspects of the client's health status, such as vital signs, fetal heart rate, contractions, cervical dilation, and pain level. However, assessing DTRs is not a routine part of labor and delivery assessment unless there are signs of preeclampsia or eclampsia.
Choice D reason: Within the first trimester of pregnancy, it is important for the nurse to assess for signs of pregnancy-related nausea and vomiting, bleeding, infection, and ectopic pregnancy. However, assessing DTRs is not a routine part of first trimester assessment unless there are signs of neurological disorders or spinal cord injury.
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Related Questions
Correct Answer is C
Explanation
Choice A reason: Providing pain medication to increase the client's tolerance of labor pains is not a specific intervention for the second stage of labor. Pain medication is a drug that relieves pain by blocking pain signals or reducing inflammation. Pain medication can be given during any stage of labor, depending on the client's preference and condition. However, pain medication may have side effects such as sedation, nausea, or respiratory depression, and may affect the fetal heart rate or the progress of labor.
Choice B reason: Assessing the fetal heart rate and pattern for signs of fetal distress is not a particular intervention for the second stage of labor. Fetal heart rate and pattern are indicators of fetal well-being and oxygenation. Fetal heart rate and pattern should be monitored throughout labor, especially during contractions, to detect any abnormalities or complications such as bradycardia, tachycardia, or decelerations.
Choice D reason: Monitoring effects of oxytocin administration to help achieve cervical dilation is not a relevant intervention for the second stage of labor. Oxytocin is a hormone that stimulates uterine contractions and cervical dilation. Oxytocin can be administered during labor to augment or induce labor, especially if there is prolonged or dysfunctional labor. However, oxytocin is not needed in the second stage of labor, when the cervix is already fully dilated and the focus is on pushing and delivering the baby.
Correct Answer is D
Explanation
Choice A: Administering a half dose now is not advisable, because it may result in underdosing or overdosing of digoxin. Digoxin has a narrow therapeutic range and a high risk of toxicity, especially in infants and children. The amount of digoxin absorbed by the infant before vomiting is unknown, so giving a partial dose may not achieve therapeutic levels or may exceed safe levels.
Choice B: Giving another dose is not advisable, because it may result in overdosing of digoxin. Digoxin has a narrow therapeutic range and a high risk of toxicity, especially in infants and children. The amount of digoxin absorbed by the infant before vomiting is unknown, so giving a full dose may exceed safe levels and cause adverse effects such as nausea, vomiting, bradycardia, arrhythmias, or visual disturbances.
Choice C: Mixing the next dose with food is not advisable, because it may affect the absorption and bioavailability of digoxin. Digoxin should be taken on an empty stomach or at least one hour before or two hours after meals, because food can interfere with its absorption from the gastrointestinal tract and reduce its effectiveness.
Choice D:Withholding the dose is the safest option. If vomiting occurs within 30 minutes of administration, it’s generally advised to skip that dose to avoid the risk of overdose.The next dose should be given as scheduled Digoxin has a long half-life and accumulates in tissues, so missing one dose will not significantly affect its therapeutic effect. Withholding this dose will avoid overdosing and toxicity of digoxin, which can be life-threatening in infants and children. The nurse should also advise the mother to resume the regular dosing schedule and monitor the infant's pulse rate and signs of digoxin toxicity.
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