A nurse is caring for a client who is receiving opioid epidural analgesia during labor. Which of the following findings is the nurse's priority?
Blood pressure 80/56 mm Hg.
The client reports profuse itching.
The client reports weakness of the lower extremities.
Temperature 38.2°C (100.8 F).
The Correct Answer is A
Choice A reason:
The nurse's priority in this situation is the client's blood pressure of 80/56 mm Hg. Opioid epidural analgesia can cause a drop in blood pressure, known as hypotension. Hypotension can be a significant concern during labor, as it may reduce blood flow to the placenta and compromise the baby's well-being. Therefore, it is crucial for the nurse to address this finding promptly to prevent any adverse effects on both the mother and the baby. The nurse may need to administer intravenous fluids, adjust the dosage of the opioid medication, or take other appropriate actions to raise the blood pressure to a safer level.
Choice B reason:
While profuse itching (choice B) can be a common side effect of opioids, it is not the nurse's priority in this situation. Itching, also known as pruritus, can be managed with antihistamines or other supportive measures, but it is not an immediate threat to the client's well-being.
Choice C reason:
The client reporting weakness of the lower extremities (choice C) is an expected side effect of epidural analgesia. Epidurals can cause temporary paralysis or weakness in the lower body due to the local anesthetic's effects on the nerves. While it's essential to monitor and support the client during this time, it is not the priority over the potentially dangerous drop in blood pressure.
Choice D reason:
A temperature of 38.2°C (100.8 F) (choice D) may indicate a fever, but it is not the nurse's priority in this specific situation of opioid epidural analgesia during labor. Fever during labor could have various causes, and the nurse should investigate and manage it appropriately. However, addressing the client's blood pressure takes precedence, as hypotension can have immediate and significant consequences.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:
Choice A is the correct answer because the number of wet diapers a newborn has per day is a reliable indicator of effective breastfeeding. When a baby is breastfeeding well and getting enough milk, they will have an adequate number of wet diapers, typically at least six to eight per day. The frequent wet diapers indicate that the baby is adequately hydrated, and their body is eliminating waste products as expected.
Choice B reason:
Choice B, having at least one breast milk stool every 24 hours, is not the most reliable indicator of effective breastfeeding, although it is an important consideration. The frequency of bowel movements can vary among breastfed infants, and some babies may have several bowel movements a day, while others may have fewer, even skipping a day. The number of wet diapers is a more consistent measure of sufficient milk intake.
Choice C reason:
Choice C, sleeping for 6 hours at a time between feedings, is not an accurate indicator of effective breastfeeding in a 4-day-old newborn. Newborns typically feed frequently, at least 8-12 times in 24 hours, and they may not sleep for extended periods between feedings at this age. Frequent feeding is essential for establishing a good milk supply and ensuring the baby receives enough nutrients.
Choice D reason:
Choice D, gaining 1 to 2 ounces per week, is also not the most reliable indicator of effective breastfeeding in the early days after birth. Weight gain can vary significantly in newborns, and a 4-day-old baby might not show the expected 1 to 2 ounces per week gain yet. Moreover, weight gain can be affected by factors other than breastfeeding, such as birth weight, initial fluid loss, and individual growth patterns.
Correct Answer is B
Explanation
A. Nalbuphine (Nubain):Nalbuphine is an opioid agonist-antagonist, which can be used to treat moderate to severe pain. However, it is not specifically used to reverse the effects of fentanyl. Administering Nalbuphine could potentially complicate the situation by introducing another opioid into the system.
B. Naloxone (Narcan):Naloxone is an opioid antagonist that rapidly reverses the effects of opioids like fentanyl. It is the standard treatment for opioid overdose and can quickly restore normal respiration in a person whose breathing has slowed or stopped due to opioid use. This makes it the most appropriate drug to have readily available in this scenario.
C. Butorphanol (Stadol):Butorphanol is another opioid agonist-antagonist used for pain relief. Similar to Nalbuphine, it is not used to reverse opioid effects and could complicate the patient's condition by adding another opioid to the system.
D. Promethazine (Phenergan):Promethazine is an antihistamine used to treat nausea, vomiting, and allergies. It does not have any properties that would counteract the effects of fentanyl. Therefore, it would not be useful in reversing opioid-induced respiratory depression.
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