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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

A hematoma presents as a localized collection of blood outside the blood vessels, causing a purplish discoloration and swelling, often resulting from trauma during delivery.

Choice B rationale

Retained placental fragments may cause postpartum hemorrhage and infection but would not present as a localized purplish swelling on the perineum.

Choice C rationale

A laceration would involve a tear in the tissue, causing bleeding and pain, but not necessarily a purplish discoloration with localized swelling unless associated with a hematoma.

Choice D rationale

Ecchymosis refers to bruising but is typically a more diffuse discoloration rather than a localized swelling and purplish area as seen with a hematoma.

Correct Answer is B

Explanation

Choice A rationale

Variable decelerations are associated with umbilical cord compression, not placenta previa. In placenta previa, the placenta covers the cervical os, but it does not typically cause

variable decelerations on fetal monitoring.

Choice B rationale

Painless vaginal bleeding is a hallmark sign of placenta previa. This occurs because the placenta is located near or over the cervical os, leading to bleeding when the cervix dilates

or effaces.

Choice C rationale

A rigid abdomen is more indicative of placental abruption, where the placenta detaches prematurely from the uterine wall, causing pain and a tense abdomen, not typically seen in

placenta previa.

Choice D rationale

Uterine tachysystole is characterized by excessive uterine contractions and is not a clinical finding related to placenta previa. Tachysystole often results from excessive oxytocin use

or other uterine stimulants.

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