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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

A) Teaching the client to treat symptoms is not sufficient; proactive monitoring is essential.

B) Continuing the drug despite signs of toxicity is not safe and may worsen the client's condition.

C) Regular monitoring of organ function is crucial to detect early signs of toxicity and prevent serious complications.

D) Discontinuing the drug without signs of toxicity may not be necessary, and the decision should be based on ongoing assessment and consultation with the healthcare provider.

A. Discuss possible opiate dependence with the client's provider. B. Note the effectiveness of the analgesia in the client's chart. C. Encourage the client to turn over, and cough and take deep breaths. D. Prepare to administer naloxone and provide respiratory support.

Correct Answer is D

Explanation

a) While discussing possible opiate dependence is important, the immediate concern is the client's respiratory depression and altered level of consciousness, which may require naloxone administration.

b) Noting the effectiveness of analgesia is relevant but does not address the current respiratory depression and lethargy observed in the client.

c) Encouraging the client to turn over and cough may not be effective in addressing severe respiratory depression, and immediate intervention is needed.

d) The client's symptoms, including drowsiness, lethargy, pinpoint pupils, and respiratory depression, are consistent with opioid overdose. Naloxone is the antidote for opioid toxicity and should be administered promptly.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is taking a drug that has potential toxic side effects. What will the nurse do?

Correct Answer is C

Explanation

A client on a morphine PCA pump is noted to be drowsy and lethargic with pinpoint pupils and the following vitals: pulse 84 beats/minute, respiratory rate 10 breaths/minute, blood pressure 90/50 mm Hg. What is the nurse's best action?

Correct Answer is D

Explanation

A client who is recovering from total knee surgery is preparing for discharge. Which of these statements indicates the client needs further teaching?

A 50-year-old postmenopausal client who has had a hysterectomy has moderate to severe hot flashes and is discussing estrogen therapy with the nurse. What will the nurse tell the client regarding the side effects of estrogen therapy?

A client who has been taking a glucocorticoid for several months arrives in the clinic. The nurse notes the client's cheeks appear full, and a prominent hump of fat is present on the upper back. The nurse will ask the provider to order which of these laboratory tests?

A prescriber has ordered medication for a newborn that is eliminated primarily by hepatic metabolism. What would the nurse expect the prescriber to order?

A nurse tells a nursing student that glucocorticoids given for rheumatoid arthritis are nearly identical to substances produced naturally by the body. The student remarks that the drug must be very safe. Which response by the nurse is correct?

The nurse is caring for a client who has an order for no food or drink by mouth and is receiving intravenous acyclovir. To prevent nephrotoxicity, what is the nurse's action?

The nurse is providing client education for a postmenopausal client; which risks associated with estrogen/progestin therapy should the nurse discuss with the client? (Select all that apply.)