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.
Free Nursing Test Bank
- Free Pharmacology Quiz 1
- Free Medical-Surgical Quiz 2
- Free Fundamentals Quiz 3
- Free Maternal-Newborn Quiz 4
- Free Anatomy and Physiology Quiz 5
- Free Obstetrics and Pediatrics Quiz 6
- Free Fluid and Electrolytes Quiz 7
- Free Community Health Quiz 8
- Free Promoting Health across the Lifespan Quiz 9
- Free Multidimensional Care Quiz 10
View Related questions
Correct Answer is B
Explanation
Choice A rationale
Holding the newborn during the initial visit may make the older sibling feel left out or jealous. Encouraging involvement with the new baby may be more beneficial.
Choice B rationale
Spending individual time with the older sibling helps them feel valued and ensures they do not feel neglected, facilitating better acceptance of the newborn.
Choice C rationale
Having the older sibling purchase a gift for the newborn can create a positive association, but it is less impactful than ensuring individual time and attention.
Choice D rationale
Postponing the introduction until discharge can increase feelings of jealousy or resentment, as the older sibling might feel excluded from the new family dynamic during a crucial time.
Correct Answer is ["B","C","D"]
Explanation
Choice A rationale
Hypertension is not a characteristic finding of hyperemesis gravidarum, which primarily affects fluid balance and nutritional status.
Choice B rationale
Dry mucous membranes are a sign of dehydration, commonly associated with hyperemesis gravidarum due to excessive vomiting.
Choice C rationale
Tachycardia can result from dehydration and electrolyte imbalances seen in hyperemesis gravidarum.
Choice D rationale
Poor skin turgor indicates dehydration, a common symptom of hyperemesis gravidarum.
Choice E rationale
Polyuria is not typical in hyperemesis gravidarum; the condition usually leads to dehydration, reducing urine output.