A nurse assesses the client and determines the client is at risk for unstable blood glucose. Which activity best reflects the planning phase of the nursing process?

A) The mother should not take any medication while breast feeding in order to prevent harm to the infant: This statement is too restrictive and not accurate. While some medications should be avoided during breastfeeding, many medications can be taken safely in small amounts. The focus should be on which medications are safe for breastfeeding, not a blanket prohibition on all medications. Some medications are compatible with breastfeeding, and the benefits of taking them may outweigh any potential risks.

B) Many medications cross into the breast milk in small amounts and could cause harm to the infant: This statement is correct. While many medications do pass into breast milk in small amounts, it’s important to recognize that some medications can pose risks to the infant depending on the type of medication, dosage, and timing of breastfeeding. Nurses should educate the mother to always consult with a healthcare provider before taking any medication while breastfeeding.

C) While medication can cross into the breast milk, no infants have ever been harmed because of this: This statement is not accurate. While many medications may pass into breast milk in small amounts, there are documented cases of infants being harmed by medications transferred via breastfeeding. It is crucial to be cautious and informed about the safety of medications taken during breastfeeding.

D) It is unlikely that a large enough amount of medication will cross into the breast milk and cause harm to the infant: While it may be true that in many cases, only small amounts of medication pass into breast milk, this statement oversimplifies the issue. The amount and type of medication, as well as the infant’s age, weight, and health, are all factors that need to be considered. Some medications may pose a significant risk to the infant, and careful evaluation is necessary.

A) Cerebral Vascular Accident (CVA): While a history of a CVA (stroke) is important to consider when prescribing medications, ondansetron is not contraindicated for clients with a history of CVA. The nurse would need to assess the client’s overall neurological status and risk factors but this condition is not an immediate concern for ondansetron use.

B) Depression: Ondansetron is not typically contraindicated in patients with depression. However, the nurse should be mindful of the potential for interactions with other medications the client may be taking for depression, but there is no direct contraindication between ondansetron and depression itself.

C) Glaucoma: This is the most concerning finding. Ondansetron can increase the risk of complications in clients with glaucoma, particularly narrow-angle glaucoma. Ondansetron has some serotonin receptor-blocking properties that can cause dilation of the pupil, which could increase intraocular pressure in clients with glaucoma. Therefore, this condition would require careful monitoring, and the nurse would need to consult with the healthcare provider before administering ondansetron to a client with glaucoma.

D) Congestive Heart Failure (CHF): While patients with CHF need to be monitored for fluid balance, ondansetron is not contraindicated in clients with CHF. The primary concern in these patients would be potential fluid retention or electrolyte imbalances, but this is generally not a direct concern for the administration of ondansetron itself.