A nurse is caring for a client who is beginning to breastfeed her newborn after delivery. The new mother states, "I don't want to take anything for pain because I am breastfeeding." Which of the following statements should the nurse make?
We can time your pain medication so that you have an hour or two before the next feeding.
You need to take pain medications so you are more comfortable.
All medications are found in breast milk to some extent.
You have the option of not taking pain medication if you are concerned.
The Correct Answer is A
Choice a) reason:
Timing the administration of pain medication can help minimize the amount of medication that passes into the breast milk. By scheduling pain relief around breastfeeding times, the nurse can ensure that the peak concentration of the medication in the blood (and therefore potentially in the milk) does not coincide with the baby's feeding times. This approach helps manage the mother's pain while also protecting the newborn from unnecessary exposure to medication.
Choice b) reason:
While managing pain is important for the mother's comfort and recovery, stating that she needs to take medication without considering her concerns about breastfeeding may not be supportive or respectful of her wishes. It's essential to address her concerns and provide options that align with her breastfeeding goals.
Choice c) reason:
It is true that all medications can be found in breast milk to some extent; however, the levels can vary widely based on the medication's properties. The nurse should provide information about the specific medication's safety during breastfeeding and discuss any potential risks with the mother.
Choice d) reason:
Informing the mother that she has the option of not taking pain medication addresses her autonomy in decision-making. However, it's also important for the nurse to discuss the potential consequences of untreated pain, such as impaired ability to care for the newborn and delayed recovery.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice a reason:
Temperature monitoring is important in preterm labor to detect infections or inflammations that could complicate the pregnancy. However, while maternal temperature is a vital sign that should be monitored, it is not the priority in this context. The priority is to assess the well-being of the fetus, which is directly indicated by the FHR.
Choice b reason:
Bowel sounds are assessed to ensure gastrointestinal function and to detect potential complications such as ileus or bowel obstruction. In the context of preterm labor, while bowel sounds are part of a comprehensive assessment, they are not the priority over fetal well-being and maternal respiratory status, especially when administering magnesium sulfate, which does not primarily affect gastrointestinal function.
Choice c reason:
Respiratory rate is a critical assessment when administering magnesium sulfate due to the risk of respiratory depression as a side effect of the medication. It is essential to monitor because maternal oxygenation directly affects fetal oxygenation. However, the FHR is a more direct measure of fetal distress and therefore takes priority in this specific assessment.
Choice d reason:
Fetal heart rate (FHR) monitoring is the priority nursing assessment when administering magnesium sulfate IV to a client in preterm labor. Magnesium sulfate can affect uterine contractions and, by extension, fetal oxygenation and well-being. FHR is the most direct indicator of fetal distress, which can occur if the uterus becomes too relaxed and compromises placental blood flow or if there are side effects affecting the mother's cardiovascular status. Therefore, continuous monitoring of FHR is crucial to ensure the fetus is not experiencing distress.
Correct Answer is D
Explanation
Choice A reason:
The statement that exposure to rubella will suppress the newborn's immune response is not entirely accurate. While rubella can affect the immune system, the primary concern with newborns is the risk of congenital rubella syndrome (CRS), which can cause a variety of health problems, including developmental delays and organ damage. The newborn's immune system is not fully developed, and while rubella can lead to immunosuppression, the main reason for isolation is to prevent the spread of the virus.
Choice B reason:
Encephalitis is an inflammation of the brain that can be caused by various infections, including rubella. However, it is not the most common complication associated with congenital rubella. The primary concerns with CRS are hearing loss, heart defects, and ocular issues, such as cataracts. While encephalitis is a serious condition, the immediate reason for isolation is to prevent the transmission of the virus, not specifically because of the risk of encephalitis.
Choice C reason:
TORCH infections refer to a group of infections that can cause serious health problems in newborns. The acronym stands for Toxoplasmosis, Other (such as syphilis), Rubella, Cytomegalovirus, and Herpes simplex virus. While it is true that the newborn is at risk for developing CRS, which is part of the TORCH group, the term "TORCH infection" is a broader category and does not specifically explain why the newborn is being isolated.
Choice D reason:
The most appropriate response is that the newborn might be actively shedding the virus. Newborns with congenital rubella can shed the virus for an extended period after birth. This means they can potentially spread the virus to others, which is why isolation is necessary. Isolation helps protect other newborns, pregnant women, and immunocompromised individuals from contracting rubella, which can have serious consequences.
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