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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? (Select all that apply.)

A.

Blood pressure.

B.

Fetal heart rate.

C.

Deep tendon reflexes.

D.

Blood glucose.

Question Solution

Correct Answer : A,B

Choice A rationale

Blood pressure should be assessed as opioid analgesics can cause hypotension, which can be detrimental to both mother and fetus during labor.

 

Choice B rationale

Fetal heart rate monitoring is essential as opioids can cross the placenta and potentially cause fetal bradycardia or distress, thus necessitating close monitoring.

 

Choice C rationale

Deep tendon reflexes are not commonly affected by opioid analgesics and therefore are not a primary assessment when administering these medications during labor.

 

Choice D rationale

Blood glucose levels are not typically influenced by opioid analgesics in the context of labor, so this is not a relevant assessment for this scenario.


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View Related questions

Correct Answer is A

Explanation

Choice A rationale

Suctioning the mouth and nose ensures that the airway is clear of any meconium-stained fluid, which can cause respiratory issues in the newborn if inhaled.

Choice B rationale

While skin-to-skin contact is beneficial for bonding and temperature regulation, ensuring the airway is clear is a higher immediate priority.

Choice C rationale

Placing the newborn under a radiant warmer helps maintain body temperature but is secondary to ensuring the airway is clear of meconium-stained fluid.

Choice D rationale

Tactile stimulation is important for encouraging breathing, but first ensuring the airway is clear takes precedence.

Correct Answer is ["B","C","D","E","F"]

Explanation

A. "I will inject this medication under your skin.": Tocolytic medications are typically administered orally, intravenously, or intramuscularly, not subcutaneously.

B. "You may experience a headache after receiving this medication."
Some tocolytic medications can cause headaches as a side effect.


C. "It is common for this medication to make you feel jittery."
Tocolytic medications, such as terbutaline, can cause nervousness or jitteriness.

D. "This medication should decrease your contractions."
The primary purpose of tocolytic medication is to decrease uterine contractions and delay preterm labor.


E. "I'll check your reflexes frequently while you are receiving this medication."
Some tocolytic medications, like magnesium sulfate, require monitoring of deep tendon reflexes to assess for potential toxicity.


F. "This medication can make your heart beat faster."
Tocolytic medications, such as terbutaline, can increase heart rate.


G. "This medication can increase your blood pressure.":

Some tocolytic medications, like magnesium sulfate, can actually lower blood pressure rather than increase it.

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