A nurse is providing teaching about the administration of gastrostomy tube feedings to the parents of an infant. Which of the following instructions should the nurse include?

Rationale for Correct Choices

• Opioid intoxication: The client’s shallow respirations, bradycardia, hypotension, slurred speech, and pinpoint pupils are classic signs of opioid overdose. The history of oxycodone use and recent psychosocial distress further support this diagnosis. Central nervous system depression from opioids suppresses respiratory drive and leads to decreased level of consciousness and low oxygen levels.

• Obtain a prescription for naloxone: Naloxone is a pure opioid antagonist that reverses respiratory and neurologic depression caused by opioid toxicity. Its rapid onset can restore breathing and consciousness, though repeated dosing may be necessary due to its short duration of action compared to most opioids.

• Prepare to initiate mechanical ventilation: The client’s respiratory rate of 10/min and oxygen saturation of 90% indicate inadequate ventilation. Mechanical ventilation may be required to maintain oxygenation and carbon dioxide elimination until the opioid’s effects subside or naloxone takes full effect.

• Respiratory rate: Monitoring respiratory rate allows evaluation of the client’s recovery and response to naloxone. Respiratory depression is the leading cause of death in opioid overdose, so continuous observation ensures early detection of deterioration or recurrence of hypoventilation as naloxone wears off.

• Pupillary reaction: Pinpoint pupils are a key diagnostic indicator of opioid intoxication. Assessing pupil size and reactivity helps determine neurologic improvement following reversal therapy. Dilation of pupils after naloxone administration signifies recovery from opioid-induced central nervous system depression.

Rationale for Incorrect Choices

• Stimulant intoxication: Stimulant toxicity causes symptoms such as tachycardia, hypertension, hyperreflexia, and dilated pupils, which contrast with the bradycardia, hypotension, and miosis seen in this client. The assessment findings are inconsistent with stimulant use.

• Alcohol intoxication: While alcohol can cause CNS depression, it does not typically produce pinpoint pupils. The presence of severe respiratory depression, bradycardia, and low blood pressure more strongly indicates opioid overdose rather than alcohol toxicity.

• Opioid withdrawal: Withdrawal symptoms include tachycardia, hypertension, restlessness, and hyperreflexia—not CNS or respiratory depression. The client’s vital signs and presentation do not align with withdrawal.

• Anticipate administering clonidine: Clonidine is used to manage opioid withdrawal symptoms, not overdose. In this scenario, the priority is reversing respiratory depression, not mitigating withdrawal discomfort.

• Collect a blood sample for ethanol level: While alcohol use disorder is part of the history, current findings point to opioid intoxication. Measuring ethanol level would not guide immediate life-saving interventions.

• Obtain prescription for restraints: The client is sedated and hypoventilating, not agitated or combative, so restraints are unnecessary and potentially harmful. The priority is airway and breathing support, not behavioral control.

• Ethanol level: Monitoring ethanol level is not relevant in an opioid overdose and would not help assess respiratory or neurologic recovery. The focus should remain on parameters directly affected by opioids.

• Hyperreflexia: Opioid toxicity causes depressed reflexes, not heightened reflexes. Monitoring hyperreflexia would not provide meaningful information about the client’s progress.

• Cardiac arrhythmias: While opioids can depress cardiac function, arrhythmias are not a primary concern in opioid intoxication. Respiratory and neurologic parameters provide more critical indicators of client improvement.

Rationale:
A. WBC count: A WBC of 13,000/mm³ is within the expected range for pregnancy, as mild leukocytosis commonly occurs due to physiologic changes, and does not require immediate reporting.

B. Fundal height: A fundal height of 27 cm at 29 weeks is slightly below average but may reflect individual variation, fetal position, or maternal factors. This finding warrants monitoring but is not an urgent concern.

C. Fetal heart rate: FHR of 158/min is within the normal range (110–160/min) for a fetus and does not indicate fetal distress, so immediate reporting is not necessary.

D. Hemoglobin: Hemoglobin of 10 g/dL is below the expected range for pregnancy (typically 11–16 g/dL). This indicates anemia, which can affect maternal and fetal oxygenation, making it important to report to the provider for further evaluation and management.