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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
To calculate the estimated date of delivery using Nägele's Rule, subtract three months from the first day of the last menstrual period (August 10), and then add seven days. However, choice A (May 20) is incorrect because it adds eight days instead of seven.
Choice B rationale:
It does not add seven days to the calculation.
Choice C rationale:
It adds three days instead of seven to the calculation
Choice D rationale:
It follows the correct application of Nägele's Rule. Subtracting three months from August 10 gives us May 10, and then adding seven days gives us May 17as the estimated date of delivery.
Correct Answer is D
Explanation
Choice A rationale:
The nurse does not need to obtain a sample of the discharge for laboratory testing at this point. Yellow discharge after circumcision is common and generally not a cause for immediate concern. Laboratory testing is not necessary for routine circumcision care.
Choice B rationale:
Applying povidone-iodine solution twice daily to the circumcision site is not recommended in this situation. Povidone-iodine may cause irritation and delay the natural healing process.
Generally, no specific cleaning solution is required for circumcision care unless otherwise indicated by a healthcare provider.
Choice C rationale:
Wiping the discharge away gently with a washcloth and warm water for the next 48 hours is not the most appropriate action. The circumcision site should be kept clean and dry, but actively wiping away the discharge may cause irritation and disrupt the natural healing process.
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