A nurse is caring for a client who is 36 weeks of gestation and experiences a spontaneous rupture of membranes. Which of the following actions should the nurse take?

Rationale:

A. Frequent swallowing: Frequent swallowing, especially of small amounts, can indicate that the child is swallowing blood from postoperative bleeding. This is a common early sign of hemorrhage following a tonsillectomy and requires immediate evaluation.

B. Increased drowsiness: Drowsiness can result from anesthesia, pain medication, or fatigue after surgery. While it should be monitored, it is not a specific indicator of postoperative hemorrhage in a child following tonsillectomy.

C. Elevated pain level: Pain is expected after tonsillectomy and does not necessarily signal bleeding. Sudden severe pain might warrant reassessment, but elevated pain alone is not a definitive sign of hemorrhage.

D. Diminished breath sounds: Diminished breath sounds are not typically associated with post-tonsillectomy hemorrhage. This finding may indicate a respiratory issue, but not specifically bleeding from the surgical site.

Rationale for correct choices:

• Opioid intoxication: The client shows hallmark signs of opioid overdose, including respiratory depression, bradycardia, hypotension, miosis (pupillary constriction), confusion, and hypothermia. A history of oxycodone use and psychosocial stressors support opioid misuse.
• Obtain prescription for naloxone: Naloxone is a competitive opioid antagonist that rapidly reverses the life-threatening effects of opioid toxicity, particularly respiratory depression and central nervous system suppression.
• Prepare to initiate mechanical ventilation: The client’s respiratory rate is critically low at 10 breaths/min with oxygen saturation at 90%. Mechanical ventilation may be necessary if the client cannot maintain adequate oxygenation even after naloxone administration.
• Respiratory rate: This is a key indicator of opioid intoxication severity and response to naloxone. Ongoing monitoring is essential to assess ventilation adequacy and detect recurrent respiratory depression.
• Pupillary reaction: Miosis is a key sign of opioid overdose, and pupil size can help gauge the severity of intoxication. As naloxone takes effect, pupils typically dilate, signaling reversal.

Rationale for incorrect choices:

• Alcohol intoxication: While the client has a history of alcohol use disorder, the physical findings (e.g., pinpoint pupils, bradycardia, low respiratory rate) are more consistent with opioid toxicity than ethanol intoxication.
• Stimulant intoxication: Stimulant overdose would present with hypertension, hyperthermia, tachycardia, and dilated pupils not the bradycardia, hypothermia, and miosis seen here.
• Opioid withdrawal: Opioid withdrawal typically presents with symptoms like dilated pupils, tachycardia, agitation, and diaphoresis—not CNS depression and hypoventilation.
• Obtain prescription for restraints: There is no evidence of violent or aggressive behavior requiring restraints; the client is sedated and obtunded, not agitated or combative.
• Collect a blood sample for ethanol level: This might be helpful later, but it does not take priority in a client presenting with acute signs of opioid overdose. Immediate interventions to support breathing are more urgent.
• Cardiac arrhythmias: Although bradycardia is present, continuous ECG monitoring may be useful, but arrhythmias are not the primary risk in opioid overdose compared to respiratory depression.
• Ethanol level: Alcohol toxicity is not the most likely cause here, so monitoring ethanol level will not help guide the immediate treatment and stabilization of this client.