A nurse is collecting data from an adolescent who is postoperative following a cesarean birth and is receiving morphine for pain. Which of the following findings is the nurse's priority?
Urinary retention
Respiratory rate 11/min
BP 105/62 mm Hg
Blurred vision
The Correct Answer is B
A) Incorrect- Urinary retention can be a concern but is not as immediately life-threatening as respiratory depression.
B) Correct - A respiratory rate of 11/min is significantly lower than the normal range and indicates respiratory depression, which can be life-threatening. It requires immediate attention.
C) Incorrect- A blood pressure of 105/62 mm Hg is within a normal range for an adolescent and does not require immediate intervention.
D) Incorrect- Blurred vision might be a side effect of medications, but respiratory depression takes priority due to its potential to lead to serious complications.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) Correct - "Progestin-only birth control pills are preferred for contraception during lactation." Progestin-only pills are generally considered safer for breastfeeding mothers as they are less likely to affect milk supply.
B) Incorrect- There is no strong evidence suggesting that taking birth control pills while breastfeeding increases the risk of breast cancer.
C) Incorrect- While breastfeeding can have contraceptive effects, relying solely on breastfeeding for contraception is not a foolproof method. It's recommended to use additional birth control methods if desired.
D) Incorrect- Birth control pills are not contraindicated for breastfeeding clients, especially if they are progestin-only pills. The preferred method, however, is progestin-only rather than combined hormonal pills.
Correct Answer is D
Explanation
A) Incorrect- Overlapping suture lines in a newborn are common and usually resolve as the baby grows. This finding is not typically concerning.
B) Incorrect- Acrocyanosis, bluish discoloration of the hands and feet, is common in newborns and is a normal physiological response to adjusting to the outside environment.
C) Incorrect- Hypotonia, or decreased muscle tone, can be present in newborns and may improve over time. It's important to monitor but may not necessarily require immediate reporting.
D) Correct - A blood glucose level of 40 mg/dL in a newborn is considered low and requires intervention. Hypoglycemia in a newborn can have serious consequences and should be promptly addressed.
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