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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

Taking iron supplements with milk is not advised because calcium in milk can interfere with the absorption of iron, reducing its effectiveness.

Choice B rationale

Doubling the dose of iron supplements if a dose is missed is not recommended because it can cause gastrointestinal issues and toxicity. It's better to just continue with the regular

dosing schedule.

Choice C rationale

Consuming 29 grams of fiber daily is a good practice for overall health, but it does not directly aid in iron absorption. Fiber can actually bind to iron and decrease its absorption in the

intestines.

Choice D rationale

Vitamin C enhances the absorption of non-heme iron (found in supplements) by converting it into a more absorbable form. Taking vitamin C with iron supplements increases their

effectiveness, making this statement correct.

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.

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