Difficulty: Medium
Average Score: 95%
Simulated
Passage / Scenario
A client who is in active labor, administered butorphanol IV bolus for painA nurse is caring for a client who is in active labor. The nurse administers butorphanol IV bolus for pain. Which of the following findings should the nurse report to the provider following this medication?
Correct answer
B
Rationale
Butorphanol can cause respiratory depression, and a respiratory rate of 10/min is below the normal range of 12 to 20 breaths per minute, indicating a need to report. Urinary output of 120 mL in 2 hr is normal, moderate fetal heart rate variability is reassuring, and blood pressure of 136/88 mm Hg is slightly elevated but not an immediate concern related to butorphanol.