A nurse is assessing the skin turgor of an older adult client. In which of the following areas should the nurse lift the skin?

Rationale for Correct Choices

• opioid intoxication: The client is drowsy, difficult to arouse, and has a respiratory rate of 10/min, all of which are hallmark findings of opioid intoxication. The presence of a needle in the antecubital space and the need for naloxone also strongly support opioid involvement. The prior history also documents opioid misuse and prior treatment with buprenorphine/naloxone, further increasing the likelihood of opioid intoxication in this episode.

• pupil characteristics: Miotic (pinpoint) pupils are a classic indicator of opioid intoxication and help differentiate it from alcohol intoxication, which typically presents with normal or enlarged pupils. The pupil response directly supports the diagnosis when paired with respiratory depression and altered level of consciousness.

Rationale for Incorrect Choices

• Alcohol withdrawal: Alcohol withdrawal presents with agitation, tremors, diaphoresis, tachycardia, hypertension, and occasionally hallucinations. This client is drowsy with decreased respiratory rate and constricted pupils, which are inconsistent with alcohol withdrawal, making this diagnosis unlikely.

• Alcohol intoxication: Alcohol intoxication often presents with slurred speech, ataxia, and altered mental status, but pupils are usually normal in size and not constricted. There is also no evidence of significant alcohol consumption reported, making alcohol intoxication less likely in this scenario.

• Opioid withdrawal: Opioid withdrawal is characterized by mydriasis (dilated pupils), diaphoresis, piloerection, tachycardia, nausea, vomiting, and agitation. The client’s current presentation of drowsiness, miotic pupils, and respiratory depression is opposite of withdrawal symptoms, ruling out opioid withdrawal.

• Amount of alcohol consumed: The client reportedly had only one beer, which is insufficient to cause coma-level depression. Alcohol intoxication severe enough to cause unresponsiveness with respiratory depression would require significantly higher intake.

• Breath sounds: Clear breath sounds do not help distinguish the cause of the altered mental status. Breath sounds are more useful for identifying respiratory complications, not for differentiating intoxication types.

• Current temperature: A normal temperature does not help identify opioid intoxication versus withdrawal. Temperature fluctuations are more common in severe withdrawal states and are not diagnostic enough to determine the underlying cause in this scenario.

Rationale:

A. Monitor the height and tone of the client's fundus: Assessing uterine fundus is essential postpartum, especially with signs of infection and moderate lochia. Monitoring for firmness, height, and consistency helps identify uterine atony or worsening infection, guiding timely interventions to prevent hemorrhage or complications.

B. Inform the client she will need to formula feed her newborn until she has received antibiotics for 24 hr: Most antibiotics prescribed for postpartum infections, such as clindamycin, are considered compatible with breastfeeding. Advising formula feeding unnecessarily could disrupt breastfeeding without clinical justification.

C. Initiate contact precautions: Postpartum infections like endometritis or mastitis are generally not spread via contact in a hospital setting. Standard precautions, including hand hygiene, are sufficient unless a specific transmissible pathogen is identified.

D. Instruct the client to wash her hands before and after changing her perineal pad: Hand hygiene prevents the spread of infection and reduces the risk of secondary infections. Teaching proper handwashing is an essential standard precaution for clients with postpartum infections.

E. Obtain a culture specimen of the lochia from the client's perineal pad using a sterile swab: Routine cultures of lochia are not indicated unless there is suspicion of an unusual pathogen or worsening infection. Assessment and empiric antibiotics are standard for postpartum endometritis based on clinical findings.

F. Encourage the client to maintain a semi-Fowler's position to enhance uterine drainage: Semi-Fowler’s positioning promotes uterine drainage, reduces stasis of lochia, and supports comfort. This position aids in preventing complications such as uterine infection or retention of lochia.

G. Request a prescription for terbutaline from the provider: Terbutaline is a tocolytic used to suppress preterm labor. It is not indicated for postpartum infection, uterine atony, or lochia management and is not appropriate in this scenario.