A 2-day old newborn is observed to be restless, irritable, sucking on its fist, and crying. What action should the nurse take first?

Feed the infant at least 1 ounce of formula.

Collect a sterile urine specimen to evaluate for drugs of abuse.

Swaddle the infant with hands near its mouth.

Move the infant into a brightly lit area for further assessment.

Answer and Explanation

The Correct Answer is C

A. Feed the infant at least 1 ounce of formula: Feeding may help if the baby is hungry, but it is not the first action in managing symptoms of NAS.
B. Collect a sterile urine specimen: This is an important step for diagnosing NAS but is not the immediate action to calm the infant.
C. Swaddle the infant with hands near its mouth: These symptoms are consistent with neonatal abstinence syndrome (NAS). Comfort measures such as swaddling and non-nutritive sucking are prioritized to soothe the infant.
D. Move the infant into a brightly lit area: A quiet, dim environment is better for soothing an overstimulated baby, so this action would be counterproductive.

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Correct Answer is C

Explanation

A. Newborns should void within 24 hours after the procedure; delays beyond 24 hours require medical attention.

B. Healing usually takes 7-10 days, not 3-5 days.

C. Applying petroleum jelly or another lubricant at each diaper change prevents the diaper from sticking to the healing site, reducing pain and promoting healing.

D. The Plastibell falls off on its own within 5-8 days and should not be forcibly removed.

A. Hemolysis of neonatal red blood cells by the maternal antibodies. B. Delayed meconium excretion resulting in the production of direct bilirubin. C. Pathological liver function resulting from hypoxemia during the birthing process. D. Physiological destruction of fetal red blood cells during the extrauterine period.

Correct Answer is D

Explanation

A. Hemolysis by maternal antibodies suggests hemolytic disease of the newborn (e.g., Rh incompatibility), which typically presents earlier and more severely.
B. Delayed meconium excretion may lead to increased bilirubin, but this is not the most common cause of jaundice at 3 days.
C. Pathological jaundice occurs within the first 24 hours or persists longer than a week.
D. Physiological jaundice is a common finding in newborns due to the natural breakdown of fetal red blood cells (RBCs) and the immature liver's inability to efficiently process bilirubin.

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Nursing Test Bank

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