A nurse is caring for a client and her newborn immediately after delivery. The client's medication history includes prenatal vitamins throughout pregnancy, one or two glasses of wine before knowing she was pregnant, occasional use of an albuterol inhaler in her last trimester, and intravenous morphine during labor. What is the nurse's most appropriate action?

Prepare the client for motor delays in the infant caused by alcohol use.

Monitor the infant's respiration and prepare to administer naloxone if needed.

Note a high-pitched cry and irritability in the infant and observe for seizures.

Administer opioids to the infant to prevent withdrawal syndrome.

Answer and Explanation

The Correct Answer is B

A) Alcohol use, even before the client knew she was pregnant, may have some impact, but it is not the primary concern immediately after delivery.

B) Intravenous morphine administration during labor can lead to respiratory depression in the newborn, and monitoring is crucial. Naloxone may be needed to reverse opioid effects.

C) A high-pitched cry and irritability may be signs of opioid withdrawal, not related to the alcohol use.

D) Administering opioids to the infant is not appropriate and could worsen any respiratory depression.

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Correct Answer is A

Explanation

a) An elevated temperature could indicate an infection, which is a serious concern in a client taking steroids, as steroids can suppress the immune system. This finding should be reported immediately.

b) Blood pressure within this range is generally acceptable and may not be a cause for immediate concern.

c) A glucose level of 128 mg/dl is within a reasonable range and may not require immediate reporting unless there are other concerning factors.

d) A heart rate of 102 beats per minute is generally within an acceptable range and may not be an immediate cause for concern in the absence of other symptoms.

Correct Answer is ["97.0"]

Explanation

- To answer the question, we need to convert pounds (lb) to kilograms (kg) using the formula: 1 lb = 0.453592 kg

- Multiply the client's weight in lb by 0.453592 to get the weight in kg: 214 lb x 0.453592 kg/lb = 97.049648 kg

- Round the answer to the nearest tenth, or one decimal place: 97.049648 kg ≈ 97.0 kg - The final answer is: The client's weight in kg is 97.0 kg

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which of these findings, from a client taking steroids, should the nurse report immediately?

Correct Answer is A

Explanation

A client weighs 214 lb. What is the clients weight in kg? (Record answer to the nearest tenth, or one decimal place. Do not use a trailing zero.)

Correct Answer is ["97.0"]

Explanation

A client who is receiving a final dose of intravenous cephalosporin complains of pain and irritation at the infusion site. The nurse observes signs of redness at the intravenous insertion site and along the vein. What is the nurse's action?

A nurse tells a nursing student that glucocorticoids given for rheumatoid arthritis are nearly identical to substances produced naturally by the body. The student remarks that the drug must be very safe. Which response by the nurse is correct?

A client who reports routine consumption of more than three alcoholic beverages per day asks about taking acetaminophen when needed for occasional recurrent pain. What will the nurse tell the client?

The nurse will include which information when teaching a client about hydroxyzine?

A nurse is reviewing the chart of an adult male client who has been taking oral androgens. Which assessment would warrant notifying the provider?

A 50-year-old postmenopausal client who has had a hysterectomy has moderate to severe hot flashes and is discussing estrogen therapy with the nurse. What will the nurse tell the client regarding the side effects of estrogen therapy?

When administering medications to infants, it is essential to remember which of the following? (Select all that apply.)

A nurse is giving discharge instructions to a client who is beginning theophylline. The nurse should tell the client that this medication might cause which of the following adverse effects?