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.)
Blood pressure.
Fetal heart rate.
Deep tendon reflexes.
Blood glucose.
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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Correct Answer is C
Explanation
Choice A rationale
Patterned breathing techniques can help in managing pain by focusing on controlled breathing, reducing anxiety, and providing a distraction from the pain, but are not specifically targeting back labor pains.
Choice B rationale
Effleurage involves light circular strokes on the abdomen and can help in managing general labor pain, but may not be as effective specifically for back labor pains.
Choice C rationale
Sacral counterpressure involves applying steady pressure to the sacral area, which can help relieve pain caused by back labor by counteracting the discomfort experienced in this
area.
Choice D rationale
Guided imagery involves using mental visualization to distract from pain and promote relaxation, but may not be as effective in relieving the specific pain associated with back labor.
Correct Answer is A
Explanation
Choice A rationale
Irregular heartbeat (palpitations or arrhythmias) can indicate a serious cardiovascular side effect of nifedipine. It requires immediate medical attention as it could compromise
maternal and fetal circulation.
Choice B rationale
Hair loss is not a known adverse effect of nifedipine and generally does not pose a significant health risk. It is more commonly associated with hormonal changes rather than
medication side effects.
Choice C rationale
Increased salivation is not a common side effect of nifedipine. Nifedipine primarily affects the cardiovascular system rather than salivary glands.
Choice D rationale
Pause is not a recognized adverse effect related to nifedipine usage. The term itself is ambiguous and not typically associated with the pharmacological profile of nifedipine.