Question

A nurse is assessing a client who has just undergone a cesarean birth and was given epidural morphine for postpartum pain relief 1 hr ago. The nurse notes that the client's RR is 10/min. What should the nurse do first?

Answer 1

The nurse should first assess the client for signs of opioid-induced respiratory depression and be ready to provide respiratory support. Immediate notification of the healthcare providers is critical, and administration of an opioid antagonist like naloxone may be necessary.

Step-by-step explanation:

If a nurse assessing a client who has had a cesarean birth and was administered epidural morphine notes that the client's respiratory rate (RR) is 10/min, the first action should be to assess the client for other signs of opioid-induced respiratory depression and prepare to provide respiratory support if necessary. This assessment can include checking oxygen saturation, assessing the level of consciousness, and evaluating whether the patient can be arused. Prompt action is crucial, as a low RR can quickly become dangerous.

The nurse should also notify the healthcare providers immediately and follow hospital protocols which may include administering an opioid antagonist such as naloxone, depending on the severity of respiratory depression and the clinical judgment of the healthcare professionals involved.