A nurse is assessing a newborn who has neonatal abstinence syndrome. Which of the following findings should the nurse expect?

Excessive crying

Decreased muscle tone

Absent Moro reflex

Diminished deep tendon reflexes

Answer and Explanation

The Correct Answer is A

Rationale:

A. Excessive crying:

Correct answer. Neonatal abstinence syndrome (NAS) often presents with irritability, inconsolable crying, and difficulty soothing.

B. Decreased muscle tone: NAS can cause hypertonia or increased muscle tone rather than decreased muscle tone.

C. Absent Moro reflex: NAS may cause hyperactive Moro reflex rather than absent.

D. Diminished deep tendon reflexes: NAS can cause hyperactive deep tendon reflexes rather than diminished.

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Free Nursing Study Resources

Correct Answer is C,A,B,D,E

Explanation

C. Instruct the client to empty their bladder.

A. Position the client supine with knees flexed and place a small rolled towel under one of their hips.
B. Palpate the fetal part positioned in the fundus.

D. Palpate the fetal parts along both sides of the uterus.

E. Palpate the fetal part positioned above the symphysis pubis.

A. Apply an ice pack to the incision site. B. Replace the surgical dressing. C. Evaluate urinary output. D. Administer 500 mL lactated Ringer's IV bolus.

Correct Answer is C

Explanation

Rationale:

A. Applying an ice pack to the incision site is not indicated for addressing vaginal bleeding after cesarean birth and may not effectively address the underlying cause.

B. Replacing the surgical dressing is not the first action to take when assessing vaginal bleeding after cesarean birth. The priority is to evaluate the client's condition and identify the cause of the bleeding.

C. Evaluating urinary output is important to assess for urinary retention, which can contribute to uterine atony and postpartum bleeding. A full bladder can interfere with uterine contraction and lead to increased bleeding.

D. Administering a lactated Ringer's IV bolus may be indicated if the client is hypovolemic due to excessive bleeding, but it is not the first action to take. Assessing urinary output and addressing potential causes of bleeding take precedence.

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A nurse is assessing a newborn who has neonatal abstinence syndrome. Which of the following findings should the nurse expect?

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Naxlex Comprehensive Predictor Exams

31. A nurse is preparing to perform Leopold maneuvers on a client who is at 36 weeks of gestation. Identify the sequence of actions the nurse should take. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps)

Correct Answer is C,A,B,D,E

Explanation

A nurse is caring for a client who delivered by cesarean birth 6 hr ago. The nurse notes a steady trickle of vaginal bleeding that does not stop with fundal massage. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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