A nurse is collecting data from an adolescent who is postoperative following a cesarean birth and is receiving morphine for pain. Which of the following findings is the nurse's priority?
Urinary retention
Respiratory rate 11/min
BP 105/62 mm Hg
Blurred vision
The Correct Answer is B
A) Incorrect- Urinary retention can be a concern but is not as immediately life-threatening as respiratory depression.
B) Correct - A respiratory rate of 11/min is significantly lower than the normal range and indicates respiratory depression, which can be life-threatening. It requires immediate attention.
C) Incorrect- A blood pressure of 105/62 mm Hg is within a normal range for an adolescent and does not require immediate intervention.
D) Incorrect- Blurred vision might be a side effect of medications, but respiratory depression takes priority due to its potential to lead to serious complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A) Incorrect- Nifedipine is a calcium channel blocker used for conditions like high blood pressure, not for controlling postpartum bleeding.
B) Incorrect- Terbutaline is a bronchodilator and is not typically used for postpartum bleeding.
C) Correct - Oxytocin is a uterotonic medication often used to control excessive bleeding after childbirth. It helps the uterus contract and reduces the risk of postpartum hemorrhage.
D) Incorrect- Betamethasone is a corticosteroid used to enhance fetal lung maturity when given to pregnant clients at risk of preterm birth
Correct Answer is C
Explanation
A) Incorrect- The water heater temperature should be set to 49.4°C (120°F) or below to prevent scalding. The given temperature is slightly too high.
B) Incorrect- Soft bumper pads in cribs can pose a suffocation risk and are not recommended.
C) Correct - Washing the newborn's face with a warm, soapy washcloth is a safe way to cleanse the baby's face. Harsh chemicals or strong soaps should be avoided.
D) Incorrect- Pillows should not be placed under a newborn's head during naps to reduce the risk of suffocation. The baby's sleep environment should be free of soft bedding.
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