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
Monitoring blood pressure every 30 minutes following epidural placement is important but not the initial action. Epidural anesthesia can lead to a sudden drop in blood pressure, so
frequent monitoring is crucial. However, the initial step should focus on preventing hypotension.
Choice B rationale
Administering lactated Ringer's 500 mL bolus via intermittent IV infusion prior to epidural placement helps in maintaining blood pressure. Epidural anesthesia can cause vasodilation,
leading to hypotension. Preloading with fluids ensures adequate blood volume and reduces the risk of a significant drop in blood pressure.
Choice C rationale
Administering oxygen via nasal cannula at 2 L/min prior to epidural placement is not necessary unless the client has respiratory complications. Oxygen supplementation is used to
treat or prevent hypoxia, which is not a primary concern in this scenario.
Choice D rationale
Repositioning the client every hour following epidural placement is important to ensure even distribution of the anesthetic and prevent pressure sores. However, this is not the initial
action to take for preventing hypotension.
Correct Answer is ["A","B","C"]
Explanation
Choice A rationale
Irregular spotting is common after the placement of an IUD as the body adjusts to the device. This is a normal side effect and typically resolves within a few months.
Choice B rationale
Avoiding tampons initially after IUD placement is advised to prevent displacement or infection. Once the IUD is properly positioned and the risk of infection decreases, tampons can generally be used.
Choice C rationale
Informed consent is required prior to IUD placement to ensure the client understands the procedure, potential risks, and benefits, ensuring an informed decision.
Choice D rationale
IUDs typically need to be replaced every 3 to 10 years, depending on the type. Replacing an IUD every 2 years is not accurate and does not align with standard medical
recommendations.