A client undergoes an above-the-knee amputation (AKA) of the right leg because of peripheral vascular disease. On the second postoperative day, the nurse enters the room to take the client's vital signs and finds the client lying in a prone position. The client asks for assistance in turning. Which action should the nurse take first?

Rationale:

• Respirations: After administering morphine, it is crucial to monitor the client's respirations because opioids can cause respiratory depression, which may be more pronounced in elderly patients or those who are in pain and immobile.
• Deep breathing techniques: The nurse should encourage deep breathing techniques. This helps improve lung expansion and reduces the risk of respiratory complications such as pneumonia and atelectasis, especially in a client with decreased mobility due to pain and injury.

Rationale for Incorrect Options:

• Heart rate: While heart rate monitoring is important, it is not the primary concern immediately after morphine administration. The client's respiratory status takes precedence, especially considering the risk of opioid-induced respiratory depression.
• Blood pressure: While blood pressure monitoring is essential, morphine administration primarily affects the respiratory system, not the circulatory system. The nurse should prioritize respiratory monitoring over blood pressure unless the patient exhibits signs of hypotension.
• Range of motion exercises: Range of motion exercises are important for mobility and rehabilitation, but they are not a priority immediately following the trauma and morphine administration. The client should be assessed and stabilized before beginning exercises.
• Joint protection techniques: Joint protection techniques are beneficial in long-term rehabilitation, but in the acute phase, the priority is to manage the fracture, pain, and prevent further complications.

A. Squeeze the nipple base to introduce milk into the mouth: This may increase the risk of aspiration if milk flows too rapidly, especially in infants with cleft lips who have difficulty forming a tight seal and managing suck-swallow coordination effectively.

B. Position the baby in the left lateral position after feeding: Although side-lying may aid digestion in some cases, it’s not the priority after feeding a newborn with cleft lip. Upright positioning is safer and helps reduce aspiration risk.

C. Alternate milk with water during the feeding: Offering water during feedings is not recommended for newborns, as it can displace nutritional intake and may disrupt electrolyte balance. It also offers no benefit for cleft lip management.

D. Hold the newborn in an upright position: This reduces the risk of aspiration by improving control of milk flow and promoting effective swallowing. It is the safest and most effective position for feeding an infant with cleft lip.