Question

A woman in labor is given fentanyl for pain. Which vital sign is a priority for the nurse to monitor in the newborn infant?

1) Pulse
2) Temperature
3) Blood pressure
4) Respiratory rate

Answer 1

The nurse must prioritize monitoring the newborn's respiratory rate if the mother was given fentanyl during labor, because this medication can lead to respiratory depression in the infant. The Apgar score, including respiratory rate, is key in assessing the baby's initial health and need for intervention at birth.

Step-by-step explanation:

In a newborn infant whose mother received fentanyl during labor, it is crucial for the nurse to monitor the respiratory rate as a priority. Fentanyl, as a potent opioid analgesic, can cross the placental barrier and has the potential to cause respiratory depression in the newborn.

To ensure the newborn's wellbeing, healthcare providers utilize the Apgar score, developed by Dr. Virginia Apgar, which assesses five criteria: skin color, heart rate, reflex, muscle tone, and respiration. The respiratory rate is particularly important as it reflects the infant's ability to effectively transition from intrauterine to extrauterine life, where the infant must breathe on its own. An Apgar score is taken at 1 minute and 5 minutes after birth, with the total score aiding in identifying if the baby is in distress and if immediate medical assistance is necessary.