The main nursing observations of the woman who receives epidural or intrathecal opioids are for all except
delayed respiratory depression.
inability to move lower extremities.
pruritus.
nausea and vomiting.
The Correct Answer is A
The correct answer is choice A, delayed respiratory depression.
Choice A reason:
Delayed respiratory depression is not one of the main nursing observations for a woman who receives epidural or intrathecal opioids. Epidural and intrathecal opioids are administered for pain relief during labor or after certain surgeries, and they act locally within the spinal cord to block pain signals. Unlike systemic opioids, which can cause respiratory depression when given in high doses, epidural and intrathecal opioids have a more limited systemic effect, reducing the risk of respiratory depression. Therefore, monitoring for delayed respiratory depression is not a primary concern in this context.
Choice B reason:
Choice B is a valid nursing observation for a woman who receives epidural or intrathecal opioids. These opioids can cause temporary paralysis or weakness in the lower extremities as a side effect of their action on the nerves in the spinal cord. Nurses need to assess the woman's ability to move her lower extremities and ensure her safety and comfort while this effect is present.
Choice C reason:
Choice C is a valid nursing observation for a woman who receives epidural or intrathecal opioids. Pruritus, which refers to itching or a sensation of itchiness, is a common side effect of opioids, including those administered via epidural or intrathecal routes. The nurse should assess the woman for any signs of pruritus and manage it appropriately if it occurs.
Choice D reason:
Choice D is a valid nursing observation for a woman who receives epidural or intrathecal opioids. Nausea and vomiting are common side effects of opioids, and they can occur after receiving these medications via epidural or intrathecal routes. The nurse should monitor the woman for any signs of nausea and vomiting and provide supportive care if needed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason:
This is incorrect because WIC does not provide immunizations for high-risk infants and children. Immunizations are provided by other health care services, which WIC may refer participants to.
Choice B reason:
This is incorrect because WIC does not screen for infants with developmental disorders. WIC provides nutrition education and referrals to other health and social services but does not diagnose or treat any medical conditions.
Choice C reason:
This is correct because WIC provides supplemental food supplies to low-income pregnant or breastfeeding women, as well as infants and children up to age 5 who are at nutritional risk. The food packages are designed to meet the special nutritional needs of the participants and include items such as fruits, vegetables, milk, cheese, cereal, bread, juice, peanut butter, eggs, and infant formula.
Choice D reason:
This is incorrect because WIC does not provide well-child examinations for infants and children living at the poverty level. WIC may refer participants to other health care services that provide such examinations but do not conduct them themselves.
Correct Answer is D
Explanation
The correct answer is choice D. Announcement of the delivery.
Choice A reason:
Support thermoregulation is a priority in nursing care of the newborn immediately after birth. Newborns are at risk of hypothermia because they have a large surface area to body mass ratio, thin skin, and limited subcutaneous fat. To prevent heat loss, newborns should be dried thoroughly, placed skin-to-skin with the mother, and covered with warm blankets.
Choice B reason:
Identifying the infant is a priority nursing care of the newborn immediately after birth. Newborns should be identified with identification bands that match those of the mother and father or significant other. This helps prevent errors in infant identification and ensures safety and security.
Choice C reason:
Promoting normal respirations is a priority nursing care of the newborn immediately after birth. Newborns need to establish effective breathing patterns to ensure adequate oxygenation and prevent complications such as respiratory distress syndrome or meconium aspiration syndrome. To promote normal respirations, newborns should be suctioned gently to clear the airway, stimulated to cry, and assessed for signs of distress.
Choice D reason:
Announcement of the delivery is not a priority in nursing care of the newborn immediately after birth. While it may be a joyful moment for the parents and family, it does not affect the health and well-being of the newborn. Therefore, it can be done later after the essential newborn care has been completed.
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