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 B
Explanation
Choice A rationale
Preparing for a cesarean birth is not an immediate necessity unless there are complications that warrant such intervention. Cesarean births are typically reserved for situations where
vaginal delivery poses a risk to the mother or the baby.
Choice B rationale
Administering IV antibiotic prophylaxis is critical in preventing potential infections during the labor process, especially given the early gestation period. This helps in safeguarding both
the mother and the fetus from infections like group B streptococcus.
Choice C rationale
Obtaining a vaginal culture is generally done to check for infections such as bacterial vaginosis or sexually transmitted infections. However, it is not an immediate priority when the
patient is already in active labor.
Choice D rationale
Administering metronidazole orally is used to treat bacterial infections but is not an immediate action required in this scenario. Metronidazole may not be the most suitable choice
during labor as it does not provide immediate infection prevention.
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.