Nokea
The nurse just administered butorphanol tartrate as prescribed to the client in active labor. Following administration of butorphanol tartrate, what is the nurse’s most important action to help prevent side effects?
- A. Assess the client’s bladder for distention
- B. Place the client on seizure precautions
- C. Assess the client’s body for itchy rash
- D. Evaluate her vital signs and pulse oximetry
Correct Answer: D
Rationale: Evaluating maternal VS and pulse oximetry would determine changes in respiratory and cardiac status. Respiratory depression in both the mother and fetus can occur with butorphanol tartrate (Stadol). Although bladder distention is a possible side effect of butorphanol tartrate, it is not common and is not the most important assessment. Seizures are not a potential side effect of butorphanol tartrate. An itchy rash is not a potential side effect of butorphanol tartrate.
You may also like to solve these questions
The pregnant client and her significant other are attending childbirth classes. The client asks for guidance on preparing her school-aged child for the new baby’s birth. Which strategies might the nurse suggest that the client use with her child? Select all that apply.
- A. Read books about bringing home a new baby.
- B. Think of unique names for the new baby.
- C. Help pack a bag for bringing the new baby home.
- D. Explain how pregnancy occurred, if asked.
- E. Help the child buy presents for the new baby.
Correct Answer: A,B,C,E
Rationale: Engaging the child in activities such as reading books about bringing the new baby home helps the child to feel a part of the experience. Engaging the child in activities such as naming the new baby helps the child to feel a part of the experience. Engaging the child in activities such as packing a bag for the new baby’s coming home helps the child to feel a part of the experience. Engaging the child in activities such as buying presents for the new baby helps the child to feel a part of the experience. Children younger than adolescents do not fully understand conception and pregnancy due to preoperational and concrete operational thinking. They are not usually asking for an explanation of sex during this time.
The pregnant client tells the nurse that she thinks she is carrying twins. In reviewing the client’s history and medical records, the nurse should determine that which factors are associated with a multiple gestation? Select all that apply.
- A. Elevated serum alpha-fetoprotein
- B. Use of reproductive technology
- C. Maternal age greater than 40
- D. History of twins in the family
- E. Elevated hemoglobin levels
Correct Answer: A,B,D
Rationale: An elevated serum alpha-fetoprotein level (an oncofetal protein normally produced by the fetal liver and yolk sac) is associated with a multiple gestation. The use of reproductive technology such as artificial insemination or fertility drugs is associated with a multiple gestation. History of twins in the family is associated with a multiple gestation. Maternal age greater than 40 is not associated with multiple gestation. An elevated Hgb is not associated with multiple gestation.
The client, who had preeclampsia and delivered vaginally 4 hours ago, is still receiving magnesium sulfate IV. When assessing the client’s deep tendon reflexes (DTRs), the nurse finds that they are both weak, at 1+, whereas previously they were 2+ and 3+. Which actions should the nurse plan? Select all that apply.
- A. Notify the client’s HCP about the reduced DTRs.
- B. Prepare to increase the magnesium sulfate dose.
- C. Prepare to administer calcium gluconate IV.
- D. Assess the level of consciousness and vital signs.
- E. Ask the HCP about drawing a serum calcium level.
Correct Answer: A,C,D
Rationale: The HCP should be notified about the decreased DTRs because weakening of these may indicate magnesium sulfate toxicity. Increasing the magnesium sulfate dose would worsen the situation and could lead to a depressed respiratory rate. Any time the client is receiving a magnesium sulfate infusion, the nurse should be prepared for the possibility of needing the antidote, calcium gluconate. The nurse should assess the client’s vital signs and level of consciousness, as decreased level of consciousness and respiratory effort are serious side effects of magnesium sulfate. The nurse should ask the HCP about drawing a serum magnesium level (not a serum calcium level) to determine whether the client is experiencing magnesium toxicity.
Which finding indicates a need for further evaluation during a prenatal visit?
- A. Blood pressure of 120/80 mmHg
- B. Trace protein in urine
- C. Weight gain of 1 pound per week
- D. Fetal heart rate of 140 bpm
Correct Answer: B
Rationale: Trace protein in urine may indicate early preeclampsia or kidney issues, warranting further evaluation.
Which response by the nurse is most accurate?
- A. Fluorescent treponemal antibody absorption (FTA-ABS) test can detect this defect.
- B. Hepatitis B surface antigen (HBsAg) test can detect this defect.
- C. Maternal serum alpha-fetoprotein (AFP) test can detect this defect.
- D. Venereal Disease Research Laboratory (VDRL) test can detect this defect.
Correct Answer: C
Rationale: The maternal serum alpha-fetoprotein (AFP) test screens for neural tube defects like spina bifida by measuring AFP levels.