An infant is in the NICU whose mother was addicted to opioids during pregnancy. The nurse knows that the most appropriate nursing intervention to help with the infant's hyperreflexia is:
Offer the infant a pacifier with a drop of mom's breast milk.
Tightly swaddle the infant
Complete the Finnegan score.
Place the infant under a radiant warmer.
The Correct Answer is C
Completing the Finnegan score is the most appropriate nursing intervention to help with the infant's hyperreflexia. The Finnegan score is a tool used to assess and monitor newborns for withdrawal symptoms related to maternal substance use during pregnancy, and hyperreflexia is one of the symptoms that can be scored using this tool. Based on the score, appropriate interventions can be implemented to address the infant's symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The question that the nurse would prioritize the least during the assessment is "Do you plan to have a vaginal or cesarean delivery?" This is because the priority at this point is to determine the urgency of the situation and assess the patient's current condition. The patient's delivery plan can be addressed later after the initial assessment is completed and the patient's stability has been established.
The other questions are all important in determining the cause and severity of the bleeding and the appropriate course of action. The question about the number of weeks is important to determine the gestational age and potential causes of bleeding, as some causes are more common in certain stages of pregnancy. The question about pain can help to determine the possible causes of bleeding and the patient's comfort level. The question about the last ultrasound is important to determine the location of the placenta and whether there are any abnormalities or potential complications.
Correct Answer is C
Explanation
This tool helps in assessing the severity of withdrawal symptoms in infants who were exposed to opioids during pregnancy. Based on the Finnegan score, the nurse can implement appropriate interventions to manage the symptoms and prevent complications. While offering the infant a pacifier with a drop of mom's breast milk or tightly swaddling the infant may be helpful for soothing the infant, these interventions may not directly address the underlying hyperreflexia associated with opioid withdrawal. Placing the infant under a radiant warmer is not indicated for managing hyperreflexia.
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