A nurse is caring for a client who has a new diagnosis of schizophrenia and a prescription for an antipsychotic medication. The nurse should recognize that which of the following indicates an adverse effect that must be reported to the provider?

Choice A reason
Administering naloxone to the newborn is not appropriate. Naloxone is an opioid antagonist used to reverse the effects of opioid overdose in adults. It is not typically used for newborns with neonatal abstinence syndrome. The management of NAS is primarily supportive, and medications may be prescribed to help manage specific withdrawal symptoms, but naloxone is not a standard treatment for NAS.

Choice B reason:

Minimizing noise in the newborn's environment is a crucial action in the plan of care is the correct action to be included. Newborns experiencing NAS can be easily overstimulated, and loud noises can exacerbate their withdrawal symptoms and distress. Creating a calm and quiet environment helps reduce agitation and promotes better sleep and overall comfort.

Choice C reason

Swaddling the newborn with his leg extended is not appropriate in this case. Swaddling can be beneficial for some newborns, but the specific positioning and swaddling techniques should be individualized based on the newborn's needs and preferences. Extending the newborn's legs may not necessarily be the best approach, as it may not provide comfort or address the symptoms associated with NAS.

Choice D reason:

Maintaining eye contact with the newborn during feedings is not appropriate in this case. While maintaining eye contact during feedings is an essential aspect of bonding and promoting parent-newborn attachment, it may not be the primary focus in managing neonatal abstinence syndrome. The plan of care for a newborn with NAS would primarily involve managing withdrawal symptoms, providing comfort measures, and addressing the newborn's unique needs during this challenging period.

Choice A reason

Setting the IV infusion pump to administer the blood over 6 hours is not the recommended rate for administering packed RBCs. Blood transfusions are typically given more rapidly, usually within 2 to 4 hours. The specific rate may vary depending on the client's condition and the provider's order.

Choice B reason

Administering the blood via a 21-gauge IV needle is not typically related to the administration of the packed RBCs. The appropriate gauge of the IV needle for blood transfusions depends on the client's condition and the type of transfusion. Larger-gauge needles are often used for blood transfusions to allow for a faster flow rate and prevent haemolysis of the blood cells.

Choice C reason

Checking the client's vital signs from the previous shift prior to the initiation of the transfusion is not sufficient for ensuring the client's safety during the blood transfusion. The nurse should assess the client's current vital signs, including temperature, heart rate, blood pressure, and respiratory rate, before initiating the transfusion. Monitoring vital signs is essential during the transfusion to detect any adverse reactions or changes in the client's condition.

Choice D reason

Rush the blood administration tubing with 0.9% sodium chloride prior to the transfusion is the correct answer. When preparing to administer a blood transfusion to an adult client with chronic anaemia, the nurse should rush the blood administration tubing with 0.9% sodium chloride (normal saline) prior to the transfusion. This process is called priming the tubing.

Priming the tubing helps remove any residual air from the tubing and ensures that the blood transfusion is administered smoothly without introducing air into the client's bloodstream. Air embolisms can be a serious complication, and priming the tubing with normal saline helps prevent this risk.