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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

A respiratory rate of 34/min is within the normal range for a newborn, which is typically between 30 to 60 breaths per minute. This does not indicate immediate distress.

Choice B rationale

Acrocyanosis, or bluish discoloration of the hands and feet, is common in newborns and usually resolves within the first few days of life. It is not a sign of critical illness.

Choice C rationale

Caput succedaneum, a swelling of the soft tissues of the newborn's scalp, is a common and benign condition that resolves on its own within a few days. It does not require immediate medical attention.

Choice D rationale

An axillary temperature of 36°C (96.8°F) is considered low and may indicate hypothermia in a newborn. Hypothermia can lead to serious complications, so this newborn requires immediate assessment and intervention to stabilize their body temperature.

Correct Answer is D

Explanation

Choice A rationale

Only one dose of rubella immunization is necessary post-delivery, no need for a second dose in 2 weeks.

Choice B rationale

Prevention of pregnancy is recommended for at least 1 month (not 4 months) after receiving the rubella vaccine to avoid possible teratogenic effects.

Choice C rationale

An additional rubella immunization is not recommended during pregnancy as the live vaccine is contraindicated during gestation.

Choice D rationale

Rubella vaccine is safe for breastfeeding mothers, as it does not affect the safety of breast milk.

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