A nurse is assessing a client 15 minutes after administering morphine sulfate 2 mg via IV push. The nurse should identify which of the following findings as an adverse effect of the medication?
Sleepy, but arousing when her name is called.
Respiratory rate 8/min.
Pain level of 6 on a scale from 0 to 10.
The Correct Answer is B
Choice A reason:
Being sleepy but arousing when her name is called is a common side effect of morphine, which is a potent opioid analgesic. Morphine can cause drowsiness and sedation, but this is not necessarily an adverse effect unless it progresses to a state where the patient cannot be easily aroused. Therefore, while this is a side effect, it is not as concerning as respiratory depression.
Choice B reason:
A respiratory rate of 8/min is an adverse effect of morphine. Opioids like morphine can depress the respiratory center in the brain, leading to a decreased respiratory rate. Normal respiratory rates for adults are typically between 12 and 20 breaths per minute. A rate of 8 breaths per minute indicates significant respiratory depression, which can be life-threatening and requires immediate intervention.
Choice C reason:
A pain level of 6 on a scale from 0 to 10 indicates that the morphine has not fully alleviated the client’s pain. While this is important to address, it is not an adverse effect of the medication. The primary concern with morphine administration is monitoring for serious side effects like respiratory depression.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: The statement “Normalcy begins to return to the community” describes the reconstruction phase of disaster response, not the heroic phase. During the reconstruction phase, efforts are focused on rebuilding and restoring the community to its pre-disaster state. This phase involves long-term recovery and the re-establishment of normalcy.
Choice B reason: The statement “Personnel are willing to work in dangerous conditions to provide assistance” accurately describes the heroic phase of disaster response. During this phase, there is an immediate and intense effort to save lives and prevent further harm. First responders, healthcare workers, and volunteers often work tirelessly and risk their own safety to provide urgent assistance and support to those affected by the disaster.
Choice C reason: The statement “Responders experience exhaustion due to extended relief efforts” pertains to the disillusionment phase of disaster response. In this phase, the initial adrenaline and motivation begin to wane, and responders may feel overwhelmed and fatigued by the prolonged demands of relief efforts. This phase can lead to burnout and a sense of frustration among responders.
Choice D reason: The statement “Survivors come together and share stories of survival” is characteristic of the honeymoon phase of disaster response. During this phase, there is a strong sense of community and solidarity among survivors. People come together to support each other, share their experiences, and find comfort in their shared resilience.
Correct Answer is A
Explanation
Choice A reason:
The statement “Fetal position is persistent occiput posterior” is correct. The occiput posterior (OP) position is when the baby’s head is down but facing the mother’s abdomen. This position can cause prolonged labor and severe backache because the baby’s head is not optimally aligned with the birth canal, making it harder for the baby to descend. The OP position often leads to more painful and prolonged labor, and it is associated with a higher likelihood of interventions such as forceps or vacuum delivery, or even cesarean section.
Choice B reason:
The statement “Maternal pelvis is gynecoid” is incorrect as a contributing cause for difficult labor. A gynecoid pelvis is the most favorable pelvic shape for childbirth. It is round and wide, providing ample space for the baby to pass through the birth canal. Women with a gynecoid pelvis typically experience smoother and less complicated deliveries.
Choice C reason:
The statement “Fetal attitude is in general flexion” is also incorrect as a contributing cause for difficult labor. General flexion is the normal fetal attitude, where the baby’s chin is tucked to the chest, and the limbs are flexed. This position allows the smallest diameter of the baby’s head to present first, facilitating an easier passage through the birth canal.
Choice D reason:
The statement “Fetal lie is longitudinal” is incorrect as a contributing cause for difficult labor. A longitudinal lie means that the baby’s spine is aligned with the mother’s spine, which is the normal and most common orientation for delivery. This position is generally favorable for childbirth.
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