A nurse is teaching a client who has migraine headaches how to use biofeedback to reduce the need for pharmacological interventions. Which of the fallowing information should the nurse include in the teaching?

Rationale:

A. Contraction intensity increased by ambulation: True labor contractions typically intensify with walking or activity, as the uterus works to dilate and efface the cervix. If contractions strengthen with movement, it suggests active labor rather than false labor.

B. Presence of bloody show: Bloody show indicates cervical changes with effacement and dilation, which are signs of true labor. Its presence helps differentiate true labor from false labor.

C. Slow change in dilation and effacement: True labor is characterized by progressive cervical change. Slow or minimal change in dilation and effacement is more consistent with false labor, but the primary hallmark is the nature of contractions.

D. Intermittent, painless contractions: False labor (Braxton Hicks contractions) is usually irregular, intermittent, and painless or minimally uncomfortable. They do not cause consistent cervical change and often subside with rest or position changes, making this a key distinguishing feature.

Rationale:

A. Bradypnea: Respiratory depression is the most serious and potentially life-threatening adverse effect of morphine, especially after IV administration when onset is rapid. Bradypnea indicates a compromised airway and inadequate ventilation, making it the nurse’s priority for immediate assessment and intervention to prevent hypoxia and respiratory arrest.

B. Sedation: Sedation is a common effect of morphine and requires monitoring, but it is less immediately dangerous than respiratory depression. The nurse should assess the depth of sedation and level of consciousness while ensuring airway safety.

C. Constipation: Constipation is a common long-term side effect of opioids, but it is not an immediate threat to life. Preventive measures can be planned, but it does not take priority over acute respiratory compromise.

D. Euphoria: Euphoria may occur with opioid administration and is generally not harmful in the short term. While the nurse should monitor for behavioral changes or signs of misuse, it does not pose an immediate risk compared with respiratory depression.