A full-term infant is admitted to the newborn nursery 2 hours after delivery.The delivery record indicates the mother is positive for human immunodeficiency virus (HIV) and received zidovudine intravenously during labor.
Which action should the nurse implement?

Choice B rationale

Providing multidisciplinary resources and ongoing support is crucial for newborns exposed to methadone. This approach helps in managing withdrawal symptoms and ensures the child receives comprehensive care.

Choice A rationale

Keeping the newborn in the nursery may be beneficial initially but does not address the long-term needs of the child and the family.

Choice C rationale

Administering methadone to the newborn is not typically done unless specifically indicated by the healthcare provider.

Choice D rationale

Calling social services for foster care placement may be necessary in some cases, but providing support and resources to the mother and child is the primary intervention.

Choice A rationale: Increasing the infusion rate of magnesium sulfate without medical approval is not appropriate. The prescribed rate should be followed unless the provider orders a change.

Choice B rationale: Assessing the client’s deep tendon reflexes and respiratory rate before administering magnesium sulfate is crucial. Magnesium sulfate can depress the central nervous system and respiratory function, so baseline assessments are necessary to identify any adverse effects early.

Choice C rationale: Stopping the infusion for variable decelerations is not the initial step. Variable decelerations may need to be addressed, but it is not the priority action before starting magnesium sulfate.

Choice D rationale: Administering an antihypertensive medication is important if the blood pressure remains elevated, but it is not specified as required before starting magnesium sulfate.