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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
a) Requesting central venous access is not the first-line response to signs of redness, pain, and irritation at the current infusion site. It's essential to address the immediate issue first.
b) Continuing the infusion while elevating the arm may exacerbate the symptoms and is not an appropriate action when there are signs of localized irritation.
c) Stopping the infusion and selecting an alternate intravenous site is the correct action to prevent further complications and assess the cause of the irritation.
d) Applying warm packs and infusing the medication at a slower rate may not be sufficient to address the observed redness and pain, and an alternate site should be considered.
Correct Answer is B
Explanation
a) A digoxin level of 1.2 ng/mL is within the therapeutic range, and holding the medication based solely on the level may not be necessary.
b) Seeing yellow-green halos is a symptom of digoxin toxicity, and holding the medication is appropriate to prevent further adverse effects.
c) Edema alone may not be a contraindication for administering digoxin; the nurse would assess other factors such as heart rate and rhythm.
d) Pacing and thirst are not specific signs of digoxin toxicity, and the nurse would need to assess other symptoms and factors before deciding to hold the medication.
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