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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 D

Explanation

Choice A rationale

Wound infection usually presents with redness, warmth, and swelling, not just yellow exudate. The presence of yellow exudate alone typically does not indicate an infection.

Choice B rationale

Ulceration would involve the breakdown of skin or tissue, which is not indicated by the presence of yellow exudate. Ulcerations are more severe and painful than normal post-

circumcision healing.

Choice C rationale

Exposure to urine can cause irritation but does not typically result in yellow exudate. Proper diapering and cleaning prevent this irritation, and exudate is part of the healing process,

not a result of urine exposure.

Choice D rationale

Healing is indicated by the presence of yellow exudate, which is a normal part of the healing process post-circumcision. It signifies that the glans is recovering as expected. .

Correct Answer is C

Explanation

Choice A rationale

Feeding from only one breast can lead to engorgement and a decrease in milk supply in the affected breast. It is important to continue breastfeeding from both breasts, even if one is infected.

Choice B rationale

Discarding milk is not necessary and can lead to a decrease in milk supply. The infection does not harm the baby, and breastfeeding helps to drain the breast and clear the infection.

Choice C rationale

Moist heat can help to increase blood flow and promote healing in the affected breast. Applying warm compresses or taking warm showers can help to reduce pain and inflammation associated with mastitis.

Choice D rationale

While staying hydrated is important for overall health, there is no specific requirement to drink at least 1500 milliliters of fluid per day for mastitis. Adequate fluid intake should be maintained, but there is no direct correlation with resolving the infection.

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