A nurse is caring for a 24-year-old female client in the postpartum unit. The client has a history of type 1 diabetes mellitus, first diagnosed at 14 years of age, and is on insulin for diabetes management. The client is gravida 1 para 1 following a spontaneous vaginal birth at 37 weeks of gestation. The newborn was large for gestational age, weighing 4.1 kg (9 lb). The client has a third-degree laceration that required several stitches.

Exhibits

Drag words from the choices below to fill in each blank in the following sentence.

Sentence: The nurse should plan to

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Choice A rationale

Diuresis, or increased urine production, is not a common adverse effect of nalbuphine hydrochloride. This medication is an opioid analgesic used for pain relief during labor.

Choice B rationale

Fever is not a typical adverse effect of nalbuphine hydrochloride. Fever may indicate an infection or other underlying condition that needs to be addressed separately.

Choice C rationale

Diarrhea is not a common adverse effect of nalbuphine hydrochloride. Opioids, including nalbuphine, are more likely to cause constipation rather than diarrhea.

Choice D rationale

Sedation is a known adverse effect of nalbuphine hydrochloride. As an opioid analgesic, it can cause drowsiness and sedation, which is important to monitor in laboring clients to ensure their safety and well-being.

Choice A rationale

Placing the newborn supine and applying pressure to the soles of the feet is not the correct method to elicit the Babinski reflex. This action does not stimulate the appropriate nerve pathways involved in the reflex.

Choice B rationale

Stroking upward on the lateral aspect of the sole of the newborn’s foot is the correct method to elicit the Babinski reflex. This action stimulates the plantar reflex, causing the big toe to extend upward and the other toes to fan out.

Choice C rationale

Pulling the newborn up by the wrist from a supine position is used to elicit the traction response, not the Babinski reflex. The traction response involves the newborn flexing their arms and attempting to lift their head.

Choice D rationale

Touching the corner of the newborn’s mouth elicits the rooting reflex, not the Babinski reflex. The rooting reflex causes the newborn to turn their head toward the stimulus and open their mouth.