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 B
Explanation
Epidural blocks are commonly used during labor to provide pain relief. However, they can also cause a sudden drop in blood pressure, known as epidural-induced hypotension, which can affect fetal oxygenation and fetal heart rate. Therefore, it is important to monitor maternal blood pressure frequently after an epidural block is administered.
While monitoring the maternal pulse is also important, hypotension is the most common complication of epidural anesthesia and can lead to decreased blood flow to the fetus. Therefore, monitoring maternal blood pressure is the priority.
Monitoring the fetus is also important, but it is not the most important intervention after an epidural block. Limiting parenteral fluids may be necessary in some cases to help prevent or treat hypotension, but it is not always necessary and should be done based on the individual situation.
Correct Answer is B
Explanation
Caput succedaneum is a common condition in newborns that causes swelling of the soft tissues of the scalp. It is usually caused by pressure on the baby's head during delivery and can be seen in both vaginal and instrumental births, such as vacuum-assisted deliveries. It generally crosses the suture lines, unlike a cephalohematoma.
Caput succedaneum is not a serious condition and generally resolves on its own within a few days without any treatment. However, the nurse should continue to monitor the newborn for signs of jaundice, which can occur due to the breakdown of red blood cells in the swelling.
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