An infant is in the NICU whose mother was addicted to opioids during pregnancy. The nurse knows that the most appropriate nursing intervention to help with the infant's hyperreflexia is:
Offer the infant a pacifier with a drop of mom's breast milk.
Tightly swaddle the infant
Complete the Finnegan score.
Place the infant under a radiant warmer.
The Correct Answer is C
Completing the Finnegan score is the most appropriate nursing intervention to help with the infant's hyperreflexia. The Finnegan score is a tool used to assess and monitor newborns for withdrawal symptoms related to maternal substance use during pregnancy, and hyperreflexia is one of the symptoms that can be scored using this tool. Based on the score, appropriate interventions can be implemented to address the infant's symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Nifedipine is a calcium channel blocker that can cause hypotension as a side effect, so the client should be advised to rise slowly from a sitting or lying position to avoid dizziness or fainting. The client does not necessarily need to be hospitalized and should continue taking the medication until a healthcare provider advises otherwise. The medication is typically continued until around 36-37 weeks gestation. There is no need to monitor respiratory rate with this medication.
Correct Answer is C
Explanation
Fetal well-being during labor is assessed by the response of the fetal heart rate (FHR) to uterine contractions (UCs). During labor, the fetal heart rate is monitored to assess the well-being of the fetus. The fetal heart rate should increase in response to fetal movement and contractions, which indicates that the fetus is receiving adequate oxygenation and blood flow. This response is called an "acceleration" in the FHR. However, accelerations alone are not enough to assess fetal well-being during labor. It is the combination of the FHR pattern with the uterine contractions pattern that provides the most information.
In addition to the FHR response to UCs, other factors that may be used to assess fetal well-being during labor include fetal scalp blood sampling, fetal pulse oximetry, and fetal ultrasound. Maternal pain control may help to decrease maternal stress and anxiety during labor, but it is not directly related to fetal well-being. An FHR above 110 beats/min is within the normal range for a fetal baseline heart rate, but it is not enough to assess fetal well-being during labor.
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