A neonate born to a mother who was abusing heroin is exhibiting signs and symptoms of withdrawal. Which signs would the nurse assess? (Select All that Apply.)

hypertonicity

excessive sneezing

low whimpering cry

overly vigorous sucking

lethargy

tremors

Answer and Explanation

Correct Answer : A,B,C,D,E,F

A. Hypertonicity: Neonates experiencing withdrawal from heroin may exhibit increased muscle tone, leading to stiffness or rigidity. This is often observed as hypertonicity in their limbs or overall body.

B. Excessive sneezing: Nasal congestion and sneezing are common symptoms in neonates undergoing withdrawal. These symptoms can occur due to the irritant effects of withdrawal on the respiratory system.

C. Low whimpering cry: Infants with neonatal abstinence syndrome (NAS) may have a weak or high-pitched cry, which may sound like whimpering. This cry can be indicative of the discomfort and distress they are experiencing.

D. Overly vigorous sucking: Neonates with NAS may display exaggerated sucking behaviors, often characterized by frantic or overly vigorous sucking during feeding or when provided with a pacifier. This behavior is a manifestation of their heightened agitation and irritability.

E. Lethargy: Some neonates experiencing NAS may appear excessively drowsy, fatigued, or have decreased responsiveness. Lethargy is a common symptom associated with withdrawal from heroin or other opioids.

F. Tremors: Tremors or shaking movements, especially when the neonate is disturbed or agitated, are hallmark signs of NAS. These tremors can be mild to severe and may affect various parts of the body, such as the arms, legs, or jaw.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is B

Explanation

A. 24 hours before birth and 24 hours after birth:

This option suggests administering Rho(D) immune globulin (RhIg) both before and after birth. However, the standard recommendation is to administer RhIg at 28 weeks' gestation and again within 72 hours after birth. Administering RhIg before birth in this manner is not a standard practice for preventing Rh isoimmunization.

B. At 28 weeks' gestation and again within 72 hours after birth:

This is the correct choice. Administering RhIg at 28 weeks' gestation helps prevent sensitization of the Rh-negative mother to Rh-positive fetal blood cells that may have entered her circulation during pregnancy. Administering it again within 72 hours after birth helps prevent sensitization from any Rh-positive fetal blood cells that may have entered the mother's circulation during delivery.

C. At 32 weeks' gestation and immediately before discharge:

Administering RhIg at 32 weeks' gestation is not the standard recommendation. The standard timing is at 28 weeks' gestation to cover the critical period of sensitization during pregnancy. Administering it immediately before discharge may not provide adequate protection if sensitization has already occurred during pregnancy.

D. In the first trimester and within 2 hours of birth:

Administering RhIg in the first trimester is not a routine practice unless there is a specific indication, such as miscarriage or invasive procedures that may lead to fetal-maternal hemorrhage. Administering it within 2 hours of birth alone does not provide adequate protection against sensitization during pregnancy. The standard recommendation is to administer RhIg at 28 weeks' gestation and again within 72 hours after birth to cover the critical periods of sensitization during pregnancy and delivery.

A. Attach a sign above her bed to have BP, IV lines, and lab work in her right arm. B. Encourage her to turn, cough, and deep breathe at frequent intervals. C. Position her right arm below heart level. D. Ask the client how she feels about having her breast removed.

Correct Answer is C

Explanation

A. Attach a sign above her bed to have BP, IV lines, and lab work in her right arm.

- This option is not appropriate because after a right-sided modified-radical mastectomy, it's generally contraindicated to use the affected arm (right arm in this case) for blood pressure measurements, IV lines, or blood draws. This is because such procedures can impede lymphatic drainage and increase the risk of lymphedema. Therefore, the unaffected arm is typically preferred for these purposes to reduce the risk of complications.

B. Encourage her to turn, cough, and deep breathe at frequent intervals.

- While turning, coughing, and deep breathing are essential postoperative nursing interventions to prevent respiratory complications such as pneumonia, they are not specific to the unique needs of a woman who has undergone a mastectomy. These interventions are more focused on general postoperative care rather than addressing the specific concerns related to mastectomy, such as lymphedema management.

C. Position her right arm below heart level.

- This is the correct choice. Positioning the right arm below heart level helps reduce swelling and promotes lymphatic drainage, particularly after surgery involving the lymph nodes, as in a mastectomy. This positioning aids in preventing complications such as lymphedema and supports optimal circulation and fluid balance in the affected arm.

D. Ask the client how she feels about having her breast removed.

- While emotional support and addressing the client's feelings are important aspects of care for a woman who has undergone a mastectomy, this intervention is more appropriate during psychosocial assessment and counseling sessions, rather than immediately postoperatively. At this stage, the focus should be primarily on physical recovery and addressing immediate postoperative needs, such as pain management and prevention of complications like lymphedema. Emotional support can certainly be provided, but it should not be the primary intervention immediately following surgery.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A neonate born to a mother who was abusing heroin is exhibiting signs and symptoms of withdrawal. Which signs would the nurse assess? (Select All that Apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

It is determined that a client's blood Rh is negative and her partner's is Rh positive. To help prevent Rh isoimmunization, the nurse would expect to administer Rho(D) immune globulin at which time?

Correct Answer is B

Explanation

A woman who has undergone a right-sided modified-radical mastectomy returns from surgery. Which nursing intervention would be most appropriate for the nurse to include in the client's plan of care at this time?

Correct Answer is C

Explanation

A sexual health public health nurse is presenting information on sexually transmitted infections (STIs) to adolescent girls and is asked, "Why are females more at risk for STIS?" Which statements by the nurse would best answer this question? Select all that apply.

A nurse is listening to a client who is a victim of intimate partner violence. The client is describing how events would unfold with the partner. The nurse interprets the client's statements and identifies which action as characteristic of the second phase of the cycle of violence?

A nurse is conducting an in-service program for a group of nurses working at the women's health facility about the causes of spontaneous abortion. The nurse determines that the teaching was successful when the group identifies which condition as the most common cause of first trimester abortions?

During a routine health check-up, a young adult woman asks the nurse about ways to prevent endometrial cancer. Which actions would the nurse most likely include? Select all that apply.

During a clinical breast examination, the nurse palpates a well-defined, firm, mobile lump in a 60-year-old woman's left breast. The nurse notifies the primary care provider. What would the nurse anticipate the care provider to prescribe next?

A neonate born to a mother who was abusing heroin is exhibiting signs and symptoms of withdrawal. Which signs would the nurse assess? (Select All that Apply.)

A pregnant woman is diagnosed with iron-deficiency anemia and is prescribed an iron supplement. After teaching her about her prescribed iron supplement, which statement indicates successful teaching?