A nurse is caring for a client and her newborn immediately after delivery. The client's medication history includes prenatal vitamins throughout pregnancy, one or two glasses of wine before knowing she was pregnant, occasional use of an albuterol inhaler in her last trimester, and intravenous morphine during labor. What is the nurse's most appropriate action?
Prepare the client for motor delays in the infant caused by alcohol use.
Monitor the infant's respiration and prepare to administer naloxone if needed.
Note a high-pitched cry and irritability in the infant and observe for seizures.
Administer opioids to the infant to prevent withdrawal syndrome.
The Correct Answer is B
A) Alcohol use, even before the client knew she was pregnant, may have some impact, but it is not the primary concern immediately after delivery.
B) Intravenous morphine administration during labor can lead to respiratory depression in the newborn, and monitoring is crucial. Naloxone may be needed to reverse opioid effects.
C) A high-pitched cry and irritability may be signs of opioid withdrawal, not related to the alcohol use.
D) Administering opioids to the infant is not appropriate and could worsen any respiratory depression.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
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Correct Answer is ["D"]
Explanation
The blood glucose reading before lunch falls within the range of 201-250 mg/dl according to the sliding scale, and the corresponding instruction is to give six units of lispro insulin.
Correct Answer is C
Explanation
A) Serum creatinine is an important marker of renal function, but specific gravity is more directly related to urine concentration and kidney function.
B) Troponin levels are primarily associated with cardiac function, not renal function.
C) Assessing specific gravity helps evaluate the kidney's ability to concentrate urine and is a valuable indicator of renal function.
D) Sodium levels can be important in assessing electrolyte balance but are not the primary indicator of renal function.
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