A nurse has received an order to administer Morphine 5mg IV once immediately.
The available concentration is 2.5 mg/mL. How many mL of morphine should the nurse prepare for administration?

Choice A rationale
Given the client’s symptoms and the fact that she is 34 weeks pregnant, the client is most likely experiencing preeclampsia. One of the severe complications of preeclampsia is eclampsia, which is characterized by the onset of seizures. Therefore, implementing seizure precautions would be an appropriate action for the nurse to take. The nurse should monitor the following parameters to assess the client’s progress: Blood pressure readings: Regular monitoring can help detect any sudden increases, which could indicate worsening preeclampsia. Urine protein levels: Protein in the urine is a common sign of preeclampsia and should be monitored regularly.
Choice B rationale
Checking deep tendon reflexes every hour could be part of the care plan for a client with preeclampsia. Hyperreflexia can be a sign of worsening preeclampsia and impending seizure activity.
Choice C rationale
Methyldopa is a medication that can be used to control blood pressure in pregnant women. However, the question does not provide information that the client has been prescribed this medication.
Choice D rationale
Monitoring neurologic status is important in a client with preeclampsia due to the risk of eclampsia, which can cause seizures and other neurologic complications. However, implementing seizure precautions is a more immediate action to address the client’s condition.

Choice A rationale
Administering oxygen via face mask is a common intervention for various complications during labor. However, it is not the priority action when late decelerations are observed on the fetal monitor. Late decelerations are a sign of fetal hypoxia, which is often caused by uteroplacental insufficiency. While oxygen administration can help increase the overall oxygen available, it does not directly address the cause of the late decelerations.
Choice B rationale
Increasing the rate of the IV fluid infusion can help improve maternal circulation and potentially increase placental perfusion. However, this intervention is not the most immediate or effective response to late decelerations.
Choice C rationale
Elevating the client’s legs is not the recommended action in response to late decelerations. This position does not alleviate the cause of late decelerations and can actually impede blood flow to the uterus.
Choice D rationale
Positioning the client on her side, specifically the left side, is the priority action when late decelerations are observed. This position helps to maximize blood flow to the uterus and placenta, thereby improving oxygen delivery to the fetus.