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 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 A
Explanation
Choice A rationale
Methadone is often prescribed to pregnant women with opioid use disorder and is considered safe for breastfeeding. Breastfeeding can provide additional benefits such as bonding
and transferring antibodies to the infant.
Choice B rationale
Methamphetamine use during pregnancy is linked to fetal growth restriction, preterm birth, and low birth weight, not fetal macrosomia (large body size).
Choice C rationale
Reducing environmental stimuli is essential for neonates exposed to substances in utero. Increased stimuli can overwhelm their underdeveloped nervous systems, leading to stress
and adverse outcomes.
Choice D rationale
Fetal alcohol syndrome is characterized by growth deficiencies, facial abnormalities, and central nervous system dysfunction. An increased head circumference is not a typical
feature; rather, microcephaly (small head circumference) is more common.