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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) Correct - Dysuria (painful urination) could indicate a urinary tract infection (UTI) which, if left untreated, can lead to complications during pregnancy. It requires prompt evaluation and treatment.
B) Incorrect- Varicose veins and gingivitis are common discomforts during pregnancy, but they are not typically considered urgent issues.
C) Incorrect- Gingivitis (inflammation of the gums) is common during pregnancy and should be addressed, but it is not as urgent as a potential UTI.
D) Incorrect- Leukorrhea (white vaginal discharge) is a common occurrence during pregnancy and is usually not a priority concern unless it's accompanied by other symptoms.
Correct Answer is D
Explanation
The correct answer is d. "I may develop discoloration on my cheeks from hormonal changes."
Choice a rationale:
- Statement:"I should expect to have burning when I urinate during the third trimester."
- Rationale:This statement is incorrect.Burning during urination is not a normal physiological change of pregnancy.It may be a sign of a urinary tract infection (UTI),which is a common infection during pregnancy.If a pregnant client experiences burning during urination,she should report it to her healthcare provider for evaluation and treatment.
Choice b rationale:
- Statement:"I may have an infection if I develop a dark line in the middle of my abdomen."
- Rationale:This statement is incorrect.A dark line in the middle of the abdomen,known as the linea nigra,is a normal physiological change of pregnancy.It is caused by hormonal changes that increase melanin production in the skin.The linea nigra typically appears in the second trimester and fades after delivery.
Choice c rationale:
- Statement:"I should expect my fingers and face to be swollen."
- Rationale:This statement is partially correct.Some swelling in the hands and face is common during pregnancy,especially in the third trimester.This is due to fluid retention caused by hormonal changes.However,excessive swelling,particularly in the hands and face,can be a sign of preeclampsia,a serious pregnancy complication.It's important to report any significant swelling to a healthcare provider.
Choice d rationale:
- Statement:"I may develop discoloration on my cheeks from hormonal changes."
- Rationale:This statement is correct.Hormonal changes during pregnancy can cause a variety of skin changes,including melasma,which is a brownish discoloration that often appears on the cheeks,forehead,and nose.Melasma is more common in women with darker skin tones and usually fades after delivery.
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