A nurse is caring for a client who is receiving morphine intravenously. Which of the following findings indicates the client is experiencing morphine toxicity?

Rationale for Correct Choices:

• Reye's syndrome: The toddler's worsening condition including vomiting, lethargy, and altered consciousness after a viral illness (influenza A) is consistent with Reye’s syndrome, which affects the liver and brain. The progression from mild viral symptoms to neurologic decline without respiratory compromise further supports this diagnosis.
• Aspirin administration: Giving aspirin during a viral illness in children is a well-known precipitant of Reye’s syndrome. The caregivers' report of alternating aspirin with acetaminophen confirms the exposure necessary to trigger the condition in a susceptible child.

Rationale for Incorrect Choices:

• Gastroenteritis: While vomiting is a feature of gastroenteritis, the absence of diarrhea and the presence of neurologic changes like lethargy and poor responsiveness make this unlikely. Additionally, the clear vomiting and lack of fluid intake without prior GI focus suggest another etiology.
• Bronchitis: Bronchitis typically causes a productive cough with wheezing, chest discomfort, and possible fever. This toddler's lungs are clear with a nonproductive cough, and neurologic signs are not typical of bronchitis.
• Acetaminophen administration: Acetaminophen is safe and commonly used to treat fever in toddlers. It is not associated with hepatic encephalopathy or neurologic complications seen in this scenario.
• Oseltamivir administration: Though oseltamivir may cause gastrointestinal side effects like nausea or vomiting, it does not explain the altered mental status and lethargy. It is also unlikely to cause such a significant clinical deterioration on its own.

Rationale:

A. Provide a low-stimulation environment: The client has a severe headache, 3+ proteinuria, and elevated BP, indicating severe preeclampsia. A quiet, low-light environment reduces the risk of seizure by limiting neurologic stimulation.

B. Maintain bed rest: Bed rest in a side-lying position improves uteroplacental blood flow and helps lower blood pressure. It also decreases metabolic demand, which is critical in hypertensive pregnancies.

C. Give antihypertensive medication: The BP readings (162/112 and 166/110 mm Hg) require immediate antihypertensive therapy to prevent cerebral hemorrhage, eclampsia, or placental abruption.

D. Obtain a 24-hr urine specimen: A 24-hour urine collection for protein is the gold standard for quantifying proteinuria and confirming the diagnosis of preeclampsia. While a dipstick of 3+ is a strong indicator, the 24-hour collection provides a definitive measurement.

E. Perform a vaginal examination every 12 hr: There are no contractions or signs of labor, so regular vaginal exams are not indicated and increase the risk of infection in a preterm pregnancy.

F. Monitor intake and output hourly: Decreased renal perfusion is a complication of preeclampsia. Hourly monitoring detects oliguria early and helps assess for fluid overload or worsening renal function.

G. Administer betamethasone: At 31 weeks, betamethasone is indicated to enhance fetal lung maturity due to risk of preterm delivery from severe maternal complications.