An infant in the neonatal intensive care unit is prescribed caffeine (Cafcit) IV as treatment for apnea. Which medical orders should the nurse plan for, based on the addition of this medication?

Question

Standard Text: Select all that apply.
1. Blood glucose measurements every 2 hours
2. Bilirubin measurement daily
3. Seizure precautions
4. Deep tendon reflex monitoring every 4 hours
5. Skin assessment every 4 hours

Answer 1

Correct Answer: 2,3
Rationale 1: While caffeine should be used with caution in clients with diabetes, there is no indication that blood glucose should be monitored every 2 hours.
Rationale 2: One of the serious adverse effects of using Cafcit in newborns is the development of kernicterus. Increasing bilirubin measurements indicate potential for development of kernicterus.
Rationale 3: One of the serious adverse effects of using Cafcit in newborns is the development of seizures.
Rationale 4: Deep tendon reflexes are monitored to see if paresthesia is developing. Paresthesia is not an adverse effect related to Cafcit.
Rationale 5: Cafcit does not result in skin disorders.
Global Rationale: One of the serious adverse effects of using Cafcit in newborns is the development of kernicterus. Increasing bilirubin measurements indicate potential for development of kernicterus. One of the serious adverse effects of using Cafcit in newborns is the development of seizures. While caffeine should be used with caution in clients with diabetes, there is no indication that blood glucose should be monitored every 2 hours. Deep tendon reflexes are monitored to see if paresthesia is developing. Paresthesia is not an adverse effect related to Cafcit. Cafcit does not result in skin disorders.