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
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. "I should avoid drinking orange juice."
- This statement is incorrect. Vitamin C, found in orange juice and other citrus fruits, can actually enhance the absorption of iron from iron supplements. Therefore, it is recommended to take iron supplements with vitamin C-rich foods or beverages to improve iron absorption. Advising the pregnant woman to avoid orange juice would be counterproductive to optimizing iron absorption.
B. "I should take my iron with milk."
- This statement is incorrect. Calcium, found in milk and dairy products, can inhibit the absorption of iron from iron supplements. Therefore, it is generally advised to avoid taking iron supplements with milk or other calcium-rich foods or beverages. Instead, iron supplements should be taken with water or vitamin C-rich foods or beverages to enhance iron absorption.
C. "I need to eat foods high in fiber."
- While it's important to maintain a balanced diet with adequate fiber intake for overall health, this statement does not directly relate to the appropriate use of iron supplements. While dietary fiber can affect digestion and bowel movements, it does not significantly impact the absorption of iron from iron supplements. Therefore, while it's beneficial to consume a diet high in fiber for various health reasons, it is not specifically necessary in relation to iron supplementation.
D. "I'll call the primary care provider if my stool is black and tarry."
- This statement is correct and indicates successful teaching. Black, tarry stools can indicate the presence of gastrointestinal bleeding, which can occur as a side effect of iron supplementation. By instructing the pregnant woman to contact her primary care provider if she experiences black, tarry stools, she demonstrates understanding of a potential adverse effect of iron supplementation and knows to seek appropriate medical attention if necessary.
Correct Answer is C
Explanation
A. Have the technician come back later on:
This option suggests delaying the blood draw until a later time when the IV line is removed or after the infusion is completed. While this may seem like a reasonable approach to avoid interfering with the IV line, it could lead to unnecessary delays in obtaining essential laboratory test results.
B. Notify the surgeon to obtain the specimen via a cut-down procedure:
This option involves a more invasive procedure, called a cut-down, which is typically reserved for situations where peripheral venous access is challenging or impossible. It involves making an incision to expose a vein for direct cannulation. This approach is not warranted in this scenario, where obtaining blood from the opposite arm is a standard and less invasive practice.
C. Tell the technician to obtain the specimen from the client's left arm:
This option is the most appropriate response. It instructs the technician to draw blood from the client's left arm, which is free from the IV line. Drawing blood from the opposite arm minimizes the risk of complications associated with interfering with the IV infusion.
D. Stop the technician immediately:
While stopping the technician immediately may prevent them from proceeding with the incorrect approach, it lacks specific guidance on how to proceed correctly. It's essential to provide clear instructions to the technician to draw blood from the opposite arm rather than simply halting the procedure without further direction.
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