A nurse is monitoring an infant who is receiving opioids for pain. Which of the following findings should indicate to the nurse that the medication is having a therapeutic effect?
Relaxed facial expression
Increased blood pressure
Limb withdrawal
Bradycardia
The Correct Answer is A
Choice A Reason:
Relaxed facial expression is correct. Opioids, when effectively managing pain, can lead to a more relaxed facial expression in infants. It's a common indicator that the pain is being controlled and the infant is experiencing relief.
Choice B Reason:
Increased blood pressure is incorrect. Opioids usually cause a decrease in blood pressure rather than an increase. Elevated blood pressure wouldn't typically signify a therapeutic effect of opioids; it might indicate other factors such as stress, discomfort, or an adverse reaction.
Choice C Reason:
Limb withdrawal is incorrect. Limb withdrawal is a reflex action and might occur in response to a stimulus. It's not a direct indicator of pain relief; rather, it's a reflexive response to a sensation.
Choice D Reason:
Bradycardia is incorrect. Bradycardia, a slowed heart rate, can be a side effect of opioid medications. However, it's not an indicator of the therapeutic effect of pain relief. In fact, bradycardia might signal an adverse reaction or a dose that's too high for the infant.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason:
Allergy to neomycin is correct. Neomycin is an antibiotic, and individuals with a known severe allergic reaction to neomycin should avoid vaccines that contain this component. The MMR vaccine, along with some other vaccines, may contain trace amounts of neomycin, and individuals with a severe allergy to neomycin might be at risk for an allergic reaction if they receive a vaccine containing this substance.
Choice BReason:
Temperature of 37.2° C (99° F) is incorrect. A low-grade fever (slight elevation in temperature) is not a contraindication for the MMR vaccine unless the fever is part of a more severe illness or if the child has a high fever or is significantly unwell.
Choice CReason:
Family history of seizures is incorrect. A family history of seizures generally does not contraindicate the MMR vaccine. However, certain specific medical conditions or individual situations related to seizures might be considered by the healthcare provider.
Choice D Reason:
Upper respiratory infection 2 days ago is incorrect. Having had a mild upper respiratory infection in the recent past, especially if the child has recovered and is feeling well without any fever, is generally not a contraindication for the MMR vaccine. However, if the child is currently acutely ill or has a fever, the vaccine might be postponed until they are feeling better.
Correct Answer is C
Explanation
Correct answer: C
Choice A Reason:
Instructing the child to drink fluids through a straw should be avoided immediately after a tonsillectomy. The sucking motion required when using a straw can potentially disrupt the healing process and dislodge the blood clot at the surgical site, leading to bleeding. Therefore, this action is not recommended.
Choice B Reason:
Avoid milk products such as milk, icecream and pudding initially because they coat the throat, causing the child to cough to clear the throat.
Choice C Reason:
Placing the child in a side-lying position helps maintain an open airway and allows drainage of saliva and potential blood.
Choice D Reason:
Encouraging the child to deep breath and cough is generally a good practice to prevent respiratory complications post-anesthesia. However, immediate post-tonsillectomy, the focus might be more on airway patency and monitoring for signs of bleeding or adverse reactions rather than deep breathing and coughing.
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