A nurse is collecting data from an adolescent who is postoperative and is receiving morphine for pain. Which of the following findings is the nurse's priority?
Respiratory rate 10/min.
Bladder distention.
BP 108/64 mm Hg.
Nausea and vomiting.
The Correct Answer is A
Choice A reason:
The nurse's priority in this situation is the respiratory rate of 10/min. A respiratory rate of 10 breaths per minute is significantly low and could indicate respiratory depression, especially if the patient is receiving morphine, which is known to depress the respiratory system. This could lead to inadequate oxygenation, potential hypoxia, and other life-threatening complications.
Choice B reason:
Bladder distention may be a concern, but it is not the nurse's priority in this situation. Bladder distention can cause discomfort and urinary retention, but it is not an immediate life- threatening condition compared to potential respiratory depression.
Choice C reason:
A blood pressure of 108/64 mm Hg is within the normal range for an adolescent and may not be the nurse's priority at this time. Although it should be monitored, it does not pose an immediate threat to the patient's life.
Choice D reason:
Nausea and vomiting are common side effects of morphine administration, but they are not the nurse's priority in this situation. While they can cause distress and discomfort to the patient, they are not life-threatening conditions.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C"]
Explanation
Choice A reason: The nurse should plan to ask the client to empty their bladder before performing Leopold maneuvers. The rationale behind this is to ensure that the client's bladder is empty to allow for better palpation of the uterus and fetal position. A full bladder can interfere with accurate assessment and may lead to incorrect findings during the examination.
Choice B reason:
The nurse should assist the client into a left-lateral position. This position is ideal for performing Leopold maneuvers because it helps to displace the uterus away from the vena cava, reducing the risk of supine hypotension syndrome. Moreover, the left-lateral position promotes optimal blood flow to the placenta, which is essential for the well-being of the fetus during the examination.
Choice C reason:
The nurse should apply an external fetal monitor to the client's abdomen after completing the Leopold maneuvers. The purpose of Leopold maneuvers is to determine the fetal position and presentation manually. Once this information is obtained, applying the external fetal monitor allows continuous monitoring of the fetal heart rate and uterine contractions to assess the baby's well-being and the progression of labor.
Choice D reason:
The nurse should not instruct the client to perform nipple stimulation when planning to assist with Leopold maneuvers. Nipple stimulation is a method to induce or augment labor, and it is not related to the process of assessing fetal position and presentation using Leopold maneuvers. It may lead to unnecessary contractions and confusion during the examination.
Correct Answer is C
Explanation
"We allow our children the freedom to decide their own behavior.”
Choice A reason:
This statement does not indicate a permissive parenting style. In fact, it suggests an authoritative or authoritarian style, where the parents make decisions for their children without considering their input. The parents' imposition of their decisions on their children's time indicates a more controlling approach.
Choice B reason:
This statement also does not reflect a permissive parenting style. Instead, it represents an authoritative or authoritarian style, where the parents expect obedience and compliance without allowing room for questions or autonomy. This approach tends to be more structured and directive.
Choice C reason:
This statement demonstrates the use of a permissive parenting style. In permissive parenting, parents tend to be lenient and allow their children considerable freedom in decision-making and behavior. By giving their children the freedom to decide their own behavior, the parents are adopting a permissive approach, which can sometimes lead to indulgence and lack of necessary boundaries.
Choice D reason:
This statement does not indicate a permissive parenting style either. Instead, it suggests an authoritative or democratic style, where the parents explain the reasoning behind the rules they set. This approach encourages understanding and cooperation but is different from permissiveness.
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