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
Related Questions
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.
Correct Answer is B
Explanation
a) Avoiding alcohol and herbal remedies is a correct instruction because they can interact with warfarin and increase the risk of bleeding.
b) Stopping warfarin abruptly without healthcare provider guidance can be dangerous and increase the risk of thrombosis. Signs of bleeding should be reported promptly to the healthcare provider for appropriate management.
c) Being consistent with the intake of leafy greens is important to maintain a stable INR, as these foods contain vitamin K, which can interfere with warfarin.
d) Regular INR monitoring is essential to ensure that the client is within the therapeutic range and to make adjustments to the warfarin dosage if necessary.
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