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 A
Explanation
The signs described are consistent with Meconium Aspiration Syndrome (MAS). Meconium aspiration occurs when the fetus has a bowel movement before or during delivery and inhales meconium-stained amniotic fluid into the lungs. This can lead to airway obstruction, chemical pneumonia, and respiratory distress, which may progress to respiratory failure, persistent pulmonary hypertension, and death. The presence of coarse breath sounds, acidosis, and the honeycomb appearance on X-ray are all signs of MAS.
Correct Answer is A
Explanation
Assessing fetal heart rate (FHR) and maternal vital signs would be the highest priority nursing intervention when admitting a pregnant woman who has experienced a bleeding episode in late pregnancy. This is because fetal distress or maternal instability may require immediate medical intervention, such as delivery via emergency cesarean section or blood transfusions, respectively.
Therefore, assessing the FHR and maternal vital signs will help to determine the urgency of the situation and guide the next steps in the management of the patient. Once the patient's condition has stabilized, performing venipuncture for hemoglobin and hematocrit levels, monitoring uterine contractions, and placing clean disposable pads to collect any drainage can be done as appropriate.
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