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 B
Explanation
The correct answer is choice B. Prolactin.
Choice A reason:
Estrogen. Estrogen is a hormone that plays a role in the development of the mammary glands and the ductal system during pregnancy. However, estrogen does not directly produce milk.
In fact, high levels of estrogen during pregnancy inhibit milk secretion by blocking prolactin. Therefore, estrogen is not the hormone necessary for milk production. • Choice B reason:
Prolactin. Prolactin is the hormone responsible for the production of breast milk. Prolactin is secreted by the pituitary gland in response to suckling or nipple stimulation. Prolactin levels rise during pregnancy and peak after delivery, when the sudden drop in estrogen and progesterone allows prolactin to take over and initiate lactation. Therefore, prolactin is the hormone necessary for milk production. • Choice C reason:
Progesterone. Progesterone is a hormone that also contributes to the development of the mammary glands and the alveoli during pregnancy. However, like estrogen, progesterone does not directly produce milk. Progesterone also inhibits milk secretion by blocking prolactin during pregnancy. Therefore, progesterone is not the hormone necessary for milk production. •
Choice D reason:
Lactogen. Lactogen is not a hormone, but a general term for any substance that stimulates lactation. There are different types of lactogens, such as human placental lactogen (hPL), which is produced by the placenta during pregnancy and has some lactogenic effects on the mammary glands. However, hPL is not the main hormone responsible for milk production. That role belongs to prolactin. Therefore, lactogen is not the hormone necessary for milk production.
Correct Answer is C
Explanation
Choice A reason:
While hypoglycemia (glucose <45 mg/dL) is concerning,58 mg/dLis within acceptable ranges for many institutions, especially in asymptomatic newborns. Monitoring is required, but it is less urgent than respiratory distress.
Choice B reason:
Respiratory rate of 78 breaths per minute is also within the normal range for a newborn, which typically ranges from 30 to 60 breaths per minute. Though respiratory rate is essential to assess, it does not take priority over other critical issues.
Choice C reason:
Newborns typically have a normal respiratory rate of30-60 breaths/minute. A rate of78indicatessignificant tachypnea, which could signal respiratory distress (e.g., transient tachypnea of the newborn, infection, or respiratory distress syndrome). Rapid breathing can lead to fatigue, hypoxia, or respiratory failure if not promptly addressed.
Choice D reason:
A glucose reading of 58 mg/dL is concerning in a newborn. Hypoglycemia (low blood glucose) can lead to serious complications if not promptly addressed. Newborns are particularly susceptible to hypoglycemia, and it requires immediate assessment and intervention.
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