Question

The nurse is monitoring a client who is recovering from a cesarean delivery with spinal anesthesia. Which sign or symptom should the nurse prioritize if noted on assessment after the administration of morphine sulfate, simethicone, and diphenhydramine?

O Slow respiration, less than 12 breaths per minute
O Abdominal distention and pain
O Intense itching manifested by scratching
O Difficulty coughing and turning

Answer 1

When monitoring a patient recovering from cesarean delivery with spinal anesthesia, priority should be given to assessing slow respiration after the administration of morphine sulfate.

Step-by-step explanation:

The nurse is monitoring a client who is recovering from a cesarean delivery with spinal anesthesia. If the patient was administered morphine sulfate, simethicone, and diphenhydramine, the sign or symptom that should be prioritized for assessment is slow respiration, specifically if the respiration rate falls below 12 breaths per minute.

This is because morphine sulfate, an opioid analgesic, can depress the central nervous system leading to respiratory depression, which is a potentially life-threatening condition. It is imperative that the nurse monitor the patient’s respiratory status closely after the administration of morphine to ensure patient safety and intervene promptly if respiratory depression occurs.