A nurse is caring for a client who is in active labor. The nurse administers butorphanol IV bolus for pain. Which of the following findings should the nurse report to the provider following this medication?
Blood pressure 136/88 mm Hg.
Moderate fetal heart rate variability.
Respiratory rate 100/min.
Urinary output 120 mL in 2 hr.
The Correct Answer is C
Choice A rationale:
Blood pressure of 136/88 mm Hg should be monitored, but it is not a finding that the nurse needs to urgently report to the provider following the administration of butorphanol. The blood pressure reading is slightly elevated but might be attributed to pain or anxiety during labor.
Choice B rationale:
Moderate fetal heart rate variability is a reassuring sign of fetal well-being and is an expected finding during labor. It does not require immediate reporting to the provider.
Choice C rationale:
Respiratory rate of 100/min is significantly increased and should be reported to the provider following the administration of butorphanol. Respiratory depression is a potential side effect of opioids like butorphanol, and a respiratory rate of 100/min raises concern for potential respiratory compromise.
Choice D rationale:
Urinary output of 120 mL in 2 hours is an acceptable finding during labor and does not require immediate reporting to the provider. Adequate urinary output varies, but generally, 30 mL/hour is considered acceptable during labor.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Requesting that the provider insert an intrauterine pressure catheter is not the immediate action the nurse should take when the umbilical cord is palpated during a vaginal examination. The priority is to relieve pressure on the cord and improve fetal oxygenation.
Choice B rationale:
Exerting continuous upward pressure on the presenting part is the correct action when the nurse palpates the umbilical cord during a vaginal examination. This manoeuvre is called "vaginal elevation,”. helps lift the presenting part off the umbilical cord, reducing the risk of cord compression and fetal distress until the provider can take further action.
Choice C rationale:
Initiating oxytocin via continuous IV infusion is not appropriate when the umbilical cord is palpated during a vaginal examination. Oxytocin can cause uterine contractions, potentially further compromising the cord and fetus.
Choice D rationale:
Placing the client in the left-lateral position is not the best immediate action for cord palpation. While the left-lateral position is useful for relieving pressure on the vena cava in cases of supine hypotensive syndrome, the priority here is to relieve cord compression, and upward pressure on the presenting part is more effective.
Correct Answer is D
Explanation
The correct answer is choice d. “The nurse should measure the newborn’s muscle tone when assigning an Apgar score.”
Choice A rationale:
The Apgar score is determined at 1 and 5 minutes after birth, not at 2 and 7 minutes.
Choice B rationale:
An Apgar score of 8 indicates that the newborn is in good health, not severe distress. Scores of 7-10 are considered normal.
Choice C rationale:
Resuscitation efforts should not be delayed until the first Apgar score is obtained. Immediate resuscitation is initiated if needed, regardless of the Apgar score.
Choice D rationale:
Muscle tone is one of the five criteria assessed in the Apgar score, along with appearance, pulse, grimace, and respiration.
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