A woman in labor receives a dose of hydromorphone hydrochloride (Dilaudid) at 11:30 a.m. She gives birth at 12:45 p.m. What action by the nurse takes priority?
A.
Assess the neonate frequently for respiratory depression.
B.
Encourage the woman to void every 2 hours postpartum.
C.
Perform a head-to-toe assessment on the neonate.
D.
Promote skin-to-skin contact and bonding as soon as possible.
ANS: A
With Dilaudid, if birth occurs within 1 to 4 hours after administration, the nurse must assess the neonate frequently for respiratory depression. The other options are appropriate, but not the priority for this situation.
You might also like to view...
To prepare for an otoscopic examination of the ear, the nurse should do which of the follow-ing?
A. Remove any hearing devices from the client's ears. B. Avoid placing fingers or hands near the client's ears. C. Place the client is a standing position. D. Ensure adequate room lighting.
Which is an appropriate nursing intervention for a child who experiences epistaxis?
1. Laying the child down and applying a warm pack. 2. Tilting the child's head back, squeezing the bridge of the nose, and applying a warm moist pack to the nose. 3. Tilting the child's head forward, squeezing the nares below the nasal bone, and applying ice to the nose. 4. Immediately packing the nares with a cotton ball soaked with phenylephrine (Neo-Synephrine).
Our personal hygiene factors are formed by ______.
a. our culture b. the practices of our family c. our own choices d. all of these
The school nurse's main focus in child abuse or neglect issues is:
a. running an abuse and neglect group b. doing psychological testing c. awareness: recognizing signs and symptoms and reporting to authorities d. working with the caregivers to change their behavior to less pathological behavior