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?

Choice A rationale

Tinnitus, a ringing sensation in the ears, is not a commonly reported adverse effect of nifedipine. Nifedipine is a calcium channel blocker primarily used to relax smooth muscle, including in the uterus and blood vessels. Its common side effects are typically related to its vasodilatory action rather than ototoxicity.

Choice B rationale

Irregular heartbeat, specifically palpitations or tachycardia, is an important adverse effect of nifedipine that warrants notifying the provider. Nifedipine can cause reflex tachycardia due to its vasodilatory effects, which can be significant in some individuals. Monitoring for and reporting changes in cardiac rhythm is crucial to ensure patient safety and appropriate management.

Choice C rationale

Hair loss, or alopecia, is not a recognized or common adverse effect associated with nifedipine therapy. The mechanism of action of nifedipine does not typically interfere with hair follicle function or growth cycles. Adverse drug reactions associated with nifedipine are generally cardiovascular or gastrointestinal in nature.

Choice D rationale

Increased salivation is not a typical or expected adverse effect of nifedipine. Common side effects of nifedipine often include dizziness, headache, flushing, peripheral edema, and nausea, primarily due to its vasodilatory properties. Changes in salivary gland function are not commonly implicated with nifedipine use.

Choice A rationale

The client's fundus is boggy and elevated above the umbilicus, deviating to the right, which indicates uterine atony. This, coupled with the saturated perineal pad and voiding of only 50 mL of urine initially, followed by 700 mL of pink-tinged urine after catheterization, suggests significant blood loss. These findings are classic signs of postpartum hemorrhage, which is often caused by uterine atony preventing effective uterine contraction and vessel compression. Normal postpartum fundal height should decrease daily.

Choice B rationale

Postpartum infection, such as puerperal sepsis, typically presents with fever, chills, uterine tenderness, and foul-smelling lochia. While the client is experiencing discomfort, there is no mention of fever or purulent discharge. The primary signs observed relate to excessive bleeding and uterine displacement, not infectious processes. A normal temperature range is 36.5°C to 37.5°C (97.7°F to 99.5°F).

Choice C rationale

Endometritis is an infection of the uterine lining, often occurring postpartum. Symptoms include fever, lower abdominal pain, uterine tenderness, and foul-smelling lochia. The client's symptoms of a boggy fundus, heavy bleeding, and fundal deviation are more indicative of a bleeding issue rather than an infection confined to the endometrium. White blood cell count would typically be elevated in infection, with a normal range being 4,500 to 11,000 cells/mm³.

Choice D rationale

A urinary tract infection (UTI) is characterized by dysuria, urgency, frequency, and sometimes hematuria. While the client reports an urge to urinate and voided a small amount, the primary and more concerning findings are related to the uterine status and excessive bleeding, which are not typical signs of a UTI. A urine culture would show bacterial growth in a UTI, with a normal urinalysis showing no or few bacteria.

Choice E rationale

Uterine inversion is a rare but severe complication where the uterus turns inside out, often presenting with sudden, severe pain, vaginal hemorrhage, and a mass protruding from the vagina. While hemorrhage is present, the description of the fundus being boggy and 2 finger breaths above the umbilicus, rather than inverted or prolapsed, makes uterine inversion less likely. The primary issue is uterine atony leading to blood loss.