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6. A nurse is caring for a woman 10 hours post-cesarean birth. She received a dose of intrathecal morphine at the time of the birth. Which of the following assessment data would require immediateintervention?a. Itching of the palms and feetb. Nauseac. Urinary output of 300 mL in the past 4 hoursd. Respiratory rate of 10 breaths/minute ANS: d Feedback a. This is a side effect of intrathecal morphine which is not life threatening. b. This is a side effect of intrathecal morphine which is not life threatening. c. A urinary output of 300 mL in 4 hours is within normal limits. d. Correct. An adverse effect of intrathecal morphine that requires immediate intervention isrespiratory distress. KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Analysis | Content Area:Maternity | Client Need: Reduction of Risk Potential |Difficulty Level: Moderate 7. A client delivered a 2800-gram neonate 4 hours ago by cesarean section with epidural anesthesia. Which of the following interventions should the nurse perform on the mother at this time? a. Maintain the client flat in bed. b. Assess the clients patellar reflexes. c. Monitor hourly urinary outputs. d. Assess the clients respiratory rate. ANS: d Feedback a. The client should be assisted to a position of comfort. b. There is no indication in the scenario that the client must have her reflexes assessed. c. The clients hydration should be monitored postsurgery, but hourly assessments are unnecessary. Maternal-Newbom Nursing: The Crtical Components Of Nursing Care, 3rd Edition, Roberta Durham, Linda Chapman d. The client has undergone major abdominal surgery. Her respiratory function should be assessedregularly. KEY: Integrated Process: Nursing Process: Implementation | Cognitive Level: Application | Content Area: Postpartum Care; Reduction of Risk Potential: Potential for Alterations in Body Systems | ClientNeed: Health Promotion and Maintenance; Physiological Integrity: Reduction of Risk Potential | Difficulty Level: Moderate 8. A post-cesarean birth woman has been diagnosed with paralytic ileus. Which of the followingsymptoms would the nurse expect to see? a. Abdominal distension b. Polyuria c. Diastasis recti d. Dependent edemaANS: a Feedback a. The nurse would expect to see a distended abdomen in a client with a paralytic ileus. b. Polyuria is unrelated to a paralytic ileus. (<] Diastasis recti is unrelated to a paralytic ileus. @ O 2