# Situation: The nurse works in the labor, operating, and postpartum units of a government hospital. A 28-year-old client had a cesarean birth under spinal anesthesia with intrathecal morphine 8 hours ago. Her urinary catheter was removed 6 hours ago and she has not voided; the bladder is palpable above the pubis. She scratches her face and chest because of itching. Her respiratory rate is 10/min, her oxygen saturation (SpO2) is 94% on room air, and she falls asleep in the middle of a sentence. Her fundus is firm with moderate lochia. What should the nurse do FIRST?

> source: MyMerci (mymerci.kr)  
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> language: ko  
> subject: Nursing Practice II — Maternal and Child Health Nursing

## 문제

Situation: The nurse works in the labor, operating, and postpartum units of a government hospital.

A 28-year-old client had a cesarean birth under spinal anesthesia with intrathecal morphine 8 hours ago. Her urinary catheter was removed 6 hours ago and she has not voided; the bladder is palpable above the pubis. She scratches her face and chest because of itching. Her respiratory rate is 10/min, her oxygen saturation (SpO2) is 94% on room air, and she falls asleep in the middle of a sentence. Her fundus is firm with moderate lochia. What should the nurse do FIRST?

## 보기

1. Catheterize her to empty the distended bladder
2. Give the antihistamine ordered for her itching
3. Rouse her, coach deep breaths, and give oxygen **✔ 정답**
4. Notify the anesthesia provider of her condition

**정답: 3**

## 해설

Falling asleep mid-sentence (Pasero sedation level 3) with a respiratory rate of 10/min signals developing opioid-induced respiratory depression; sedation comes before respiratory arrest, and intrathecal morphine can cause it for up to about 24 hours. Breathing comes first, so the nurse stays with her, rouses her, coaches deep breaths, and gives oxygen, then calls the anesthesia provider and gives naloxone as ordered. Urinary retention and itching are also morphine effects that need care, but only after breathing is supported.

## 심화 해설

Priority-setting rationale

The first step is to recognize that this client is exhibiting opioid-induced respiratory depression from intrathecal morphine administered 8 hours ago. The combination of a respiratory rate of 10/min, SpO2 94% on room air, and falling asleep in the middle of a sentence indicates progressive sedation that precedes respiratory arrest. Sedation always occurs before opioid-induced respiratory depression becomes life-threatening, so the nurse must intervene at the level of arousal and ventilation before addressing other morphine-related effects.

Why breathing is the immediate priority

Intrathecal morphine migrates rostrally in the cerebrospinal fluid and can depress the brainstem respiratory centers for up to 24 hours after injection . The client’s sedation level corresponds to Pasero Opioid-Induced Sedation Scale level 3—sleeping but arousable, falling asleep during conversation—which is a Watch out! warning sign that respiratory depression is developing. A respiratory rate of 10/min with marginal oxygenation confirms that ventilatory drive is already compromised. The nurse must stay with the client, rouse her, coach deep breathing, and apply oxygen to support ventilation and oxygenation immediately.

Why the other options are secondary

Urinary retention with a palpable bladder and facial/chest pruritus are both well-documented adverse effects of intrathecal morphine [2]. However, neither is immediately life-threatening. Catheterization for bladder distention and antihistamine administration for itching can be safely deferred until the airway, breathing, and circulation are stabilized. Notifying the anesthesia provider is appropriate but should occur after the nurse has initiated direct interventions to support breathing; the provider will likely order naloxone and increased monitoring, but the nurse’s first action is at the bedside.

| Assessment finding | Clinical significance | Priority |
| --- | --- | --- |
| RR 10/min, SpO2 94%, sedation level 3 | Opioid-induced respiratory depression; sedation precedes apnea | Immediate—support breathing and oxygenation |
| Bladder palpable above pubis, no voiding for 6 hours | Urinary retention from intrathecal morphine | Delayed—catheterize after respiratory stability |
| Facial and chest pruritus | Morphine-induced histamine release or central pruritus | Delayed—antihistamine after respiratory stability |
| Firm fundus, moderate lochia | Normal postpartum uterine tone and bleeding | Reassuring—continue routine monitoring |

Monitoring implications from the evidence

The Society for Obstetric Anesthesia and Perinatology recommends respiratory monitoring after cesarean delivery based on intrathecal morphine dose, reflecting the recognized risk of delayed respiratory depression . Dose-dependent adverse effects, including sedation and respiratory depression, support the trend toward lower intrathecal morphine doses, but even standard doses require vigilant nursing surveillance . The nurse’s role is to detect early sedation changes and intervene before respiratory failure progresses.

Rousing the client, coaching deep breaths, and giving oxygen directly addresses the reversible cause of hypoventilation and buys time for pharmacologic reversal with naloxone. Key point! Sedation level is the earliest and most reliable clinical indicator of impending opioid-induced respiratory depression; a client who falls asleep mid-sentence requires immediate stimulation and respiratory support, not just observation.References (research sources)

- [2]Prevalence and management of intrathecal morphine-induced pruritus in New Zealand Māori healthcare recipients.Research articleWoods JM, Lim AG (2018) · DOI: 10.1177/2049463717719773

## 임상 시나리오

Opioid-Induced Respiratory Depression After Intrathecal MorphineSedation precedes respiratory arrest: intervene at the first warning sign
Intrathecal morphine can cause delayed respiratory depression for up to 24 hours. Falling asleep mid-sentence is Pasero sedation level 3, a warning sign that ventilatory drive is already compromised.

The immediate priority is to stay with the client, rouse her, coach deep breaths, and apply oxygen. A respiratory rate of 10/min with SpO2 94% on room air confirms the need for ventilatory support before any other intervention.

CautionNever leave a sedated post-cesarean client alone. After initiating oxygen and arousal, notify the anesthesia provider and prepare to give naloxone as ordered. Urinary retention and pruritus are secondary concerns.

## 핵심 개념

- **Pasero Opioid-Induced Sedation Scale** — A sedation assessment tool; level 3 (sleeping but arousable, falling asleep during conversation) is a warning sign of impending opioid-induced respiratory depression.
- **Intrathecal morphine** — Opioid administered into the cerebrospinal fluid; can cause delayed respiratory depression for up to 24 hours due to rostral migration to brainstem respiratory centers.
- **Opioid-induced respiratory depression** — Life-threatening decrease in ventilatory drive caused by opioid action on brainstem respiratory centers; sedation always precedes respiratory arrest.
- **Spinal anesthesia** — Regional anesthesia involving injection of local anesthetic and sometimes opioid into the subarachnoid space; used for cesarean birth.
- **Naloxone** — Opioid antagonist used to reverse opioid-induced respiratory depression; given as ordered after immediate ventilatory support is initiated.

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