A nurse is caring for a client who is in active labor.

Exhibits

The nurse is caring for a client following the insertion of an epidural. For each nursing intervention, click to specify if the intervention is essential or contraindicated for the client.

Potential Condition: Opioid intoxication

Actions to Take:

1. Obtain a prescription for naloxone
2. Prepare to initiate mechanical ventilation

Parameters to Monitor:

1. Pupillary reaction,
2. Respiratory rate

Rationale:

• Potential Condition: The client presents with shallow breathing, slurred speech, confusion, pupillary constriction, and bradycardia, which are classic signs of opioid intoxication. The history of back pain also suggests possible opioid use.
• Actions to Take:
  • Naloxone is an opioid antagonist that can rapidly reverse respiratory depression caused by opioid overdose.
  • Mechanical ventilation may be necessary if respiratory depression is severe and does not improve with naloxone administration.
• Parameters to Monitor:
  • Pupillary reaction is important because opioids cause pupillary constriction (miosis). Improvement in pupillary size and reaction indicates the opioid effects are wearing off.
  • Respiratory rate should be closely monitored since opioid overdose primarily affects respiratory drive, leading to hypoxia and potential respiratory failure.

A. The client has been in the restraints for 4 hr. This is incorrect because the duration of restraint use is determined by the client's behavior and safety, not a set time frame. Restraints should be discontinued as soon as they are no longer necessary.
B. The client can explain the reasons for their behavior. This is incorrect because insight into behavior does not necessarily indicate that the client is no longer a danger to themselves or others.
C. The client is able to calmly follow commands. This is correct because the primary indication for removing restraints is when the client demonstrates self-control and the ability to follow directions, reducing the risk of harm.
D. The client reports that the restraints are too tight. This is incorrect because a complaint of tight restraints indicates a need for reassessment and possible adjustment, but not necessarily discontinuation.