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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A reason:

If the client reports frequent uterine contractions , it is not indicative of a distended bladder. Postpartum uterine contractions are normal and necessary to help the uterus return to its pre-pregnancy size.

Choice B reason:

The fundus (the top portion of the uterus being palpable to the right of the midline suggests a distended bladder. A full bladder can displace the uterus, causing the fundus to deviate from the midline.

Choice C reason:

Having less than 2.5 cm of rubra lochia on a perineal pad is related to the amount of vaginal discharge after birth and does not provide information about bladder distention.

Choice D reason:

The client's report of increased thirst may indicate dehydration or the body's response to fluid loss during childbirth but is not directly related to bladder distention.

A. Assist the client into a comfortable position. B. Observe the perineum for signs of crowning. C. Have the client pant during the next contractions. D. Help the client to the bathroom to void.

Correct Answer is C

Explanation

Choice A reason:

While positioning is important for comfort during labor, addressing the immediate urge to push takes priority. Panting during contractions is the appropriate action.

Choice B reason:

Although observing for crowning is important when the client is close to delivery, the nurse should first intervene to address the client's urge to push since the client is only 7 cm dilated.

Choice C reason:

When a laboring client feels the urge to push but is not yet fully dilated (10 cm), encouraging her to pant can help reduce the urge to push and avoid complications, such as cervical swelling or tearing. This breathing technique helps the client delay pushing until full dilation and readiness of the cervix.
Choice D reason:

Assisting the client to the bathroom would not be appropriate at this stage of labor because the urge to push could lead to unsafe delivery outside the appropriate setting, and movement could increase discomfort or risks.

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The main nursing observations of the woman who receives epidural or intrathecal opioids are for all except

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is 2 hours postpartum following a vaginal birth. Which of the following findings indicates the client's bladder is distended?

Correct Answer is B

Explanation

A nurse is caring for a client who is in active labor with 7 cm of cervical dilation and 100% effacement. The fetus is at 1+ station, and the client's amniotic membranes are intact. The client suddenly states that she needs to push. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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