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

Answer and Explanation

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.

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Correct Answer is D

Explanation

A) Incorrect- Using a breast pump can actually help relieve breast engorgement by expressing excess milk, so this advice is not appropriate.
B) Incorrect- Applying ice packs to the breasts can decrease milk production and might not provide as much relief as other interventions.
C) Incorrect- Wearing a supportive, well-fitting bra is a good recommendation, but it might not provide enough relief for breast engorgement on its own.
D) Correct - Applying purified lanolin to the breasts can help soothe and moisturize the nipples, making breastfeeding more comfortable and providing relief from breast engorgement.

A. Overlapping suture lines B. Acrocyanosis C. Hypotonia D. Blood glucose level 40 mg/dL

Correct Answer is D

Explanation

A) Incorrect- Overlapping suture lines in a newborn are common and usually resolve as the baby grows. This finding is not typically concerning.
B) Incorrect- Acrocyanosis, bluish discoloration of the hands and feet, is common in newborns and is a normal physiological response to adjusting to the outside environment.
C) Incorrect- Hypotonia, or decreased muscle tone, can be present in newborns and may improve over time. It's important to monitor but may not necessarily require immediate reporting.
D) Correct - A blood glucose level of 40 mg/dL in a newborn is considered low and requires intervention. Hypoglycemia in a newborn can have serious consequences and should be promptly addressed.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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