A newborn in the nursery is exhibiting signs of intrauterine drug exposure. Which of the following signs/symptoms is the nurse observing? (Select all that apply)
Calm, easy to comfort
Tremors
Persistent shrill cry
Difficult to console
Correct Answer : B,C,D
Choice A) Calm, easy to comfort is incorrect because this is not a sign of intrauterine drug exposure, but rather a sign of normal or healthy newborn behavior. Newborns who are calm and easy to comfort are usually well-adjusted and have a good temperament. They respond positively to soothing techniques such as holding, rocking, or singing.
They do not show signs of distress or withdrawal, which are common in newborns who are exposed to drugs in utero. Therefore, this response is irrelevant and inaccurate.
Choice B) Tremors is correct because this is a sign of intrauterine drug exposure that can indicate neurological damage or withdrawal syndrome. Tremors are involuntary shaking or quivering movements of the body or limbs that occur due to abnormal electrical activity in the brain or nervous system. Newborns who are exposed to drugs such as opioids, cocaine, or alcohol in utero may develop tremors as a result of brain injury, hypoxia, hypoglycemia, or seizures. They may also experience tremors as a symptom of neonatal abstinence syndrome (NAS), which is a condition that occurs when the newborn stops receiving the drug from the mother and goes through withdrawal. NAS can cause various physical and behavioral problems in the newborn, such as irritability, poor feeding, vomiting, diarrhea, sweating, fever, or seizures. Therefore, this response is clear and accurate.
Choice C) Persistent shrill cry is correct because this is a sign of intrauterine drug exposure that can indicate pain or discomfort in the newborn. Crying is a normal and natural way for newborns to communicate their needs and feelings. However, some newborns who are exposed to drugs such as opioids, cocaine, or alcohol in utero may cry more often, louder, or longer than usual. They may have a high-pitched or piercing cry that is difficult to soothe or stop. This may be due to various factors such as hunger, colic, infection, injury, or withdrawal. A persistent shrill cry can also affect the bonding and attachment between the newborn and the parents or caregivers. Therefore, this response is clear and accurate.
Choice D) Difficult to console is correct because this is a sign of intrauterine drug exposure that can indicate emotional or behavioral problems in the newborn. Newborns who are difficult to console are usually unhappy and restless. They do not respond well to soothing techniques such as holding, rocking, or singing. They may have trouble sleeping, feeding, or interacting with others. They may also show signs of agitation, anxiety, or depression. These problems may be caused by exposure to drugs such as opioids, cocaine, or alcohol in utero, which can affect the development and function of the brain and nervous system. They may also be influenced by the environment and relationship of the newborn with the parents or caregivers. Therefore, this response is clear and accurate.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice a) 100 to 120 is incorrect because this is too low for a normal newborn's heart rate. The heart rate of a newborn is influenced by factors such as gestational age, activity level, temperature, and health status. A full-term, quiet, alert newborn should have a heart rate between 120 and 160 beats per minute, which reflects their high metabolic rate and oxygen demand. A heart rate below 100 beats per minute may indicate bradycardia, which can be caused by hypoxia, hypothermia, or cardiac problems.
Choice b) 120 to 160 is correct because this is the normal range for a full-term, quiet, alert newborn's heart rate. The apical pulse is the best way to measure the heart rate of a newborn, as it reflects the actual contractions of the heart. The apical pulse can be auscultated at the fourth intercostal space on the left side of the chest, just below the nipple line. The nurse should count the apical pulse for a full minute, as it may vary with the respiratory cycle.
Choice c) 80 to 100 is incorrect because this is also too low for a normal newborn's heart rate. A full-term, quiet, alert newborn should have a heart rate between 120 and 160 beats per minute, which is higher than that of an adult or an older child. A heart rate below 100 beats per minute may indicate bradycardia, which can be caused by hypoxia, hypothermia, or cardiac problems.
Choice d) 150 to 180 is incorrect because this is too high for a normal newborn's heart rate. A full-term, quiet, alert newborn should have a heart rate between 120 and 160 beats per minute, which is lower than that of a preterm or a crying newborn. A heart rate above 160 beats per minute may indicate tachycardia, which can be caused by fever, infection, anemia, or hyperthyroidism.
Correct Answer is B
Explanation
Choice A: This is incorrect because Standard Precautions are a set of guidelines that apply to all patients, regardless of their infection status. They include using personal protective equipment, handling sharps and waste properly, and cleaning and disinfecting equipment and surfaces. However, they are not enough to prevent neonatal infection, as some pathogens can still be transmitted by contact or droplet.
Choice B: This is the correct answer because good hand hygiene is the most effective way to prevent the transmission of microorganisms that can cause neonatal infection. The nurse should wash their hands with soap and water or use an alcohol-based hand rub before and after touching the infant, the infant's environment, or any items that come in contact with the infant. The nurse should also educate the parents and visitors on the importance of hand hygiene and how to perform it correctly.
Choice C: This is incorrect because a separate gown technique involves wearing a clean gown for each infant and discarding it after use. This can help prevent cross-contamination between infants, but it does not eliminate the need for hand hygiene. The nurse should still wash their hands before and after wearing a gown, as well as before and after touching the infant or any items that come in contact with the infant.
Choice D: This is incorrect because isolation of infected infants involves placing them in a separate room or area with restricted access and using additional precautions based on the mode of transmission of the infection. This can help prevent the spread of infection to other infants, staff, or visitors, but it does not eliminate the need for hand hygiene. The nurse should still wash their hands before and after entering and leaving the isolation area, as well as before and after touching the infant or any items that come in contact with the infant.
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