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
The Correct Answer is A
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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Related Questions
Correct Answer is A
Explanation
A.
Rationale:
A. The McRoberts maneuver involves flexing the mother's thighs onto her abdomen to straighten the pelvis and allow for easier passage of the baby's shoulder. This action helps to widen the pelvic outlet and facilitate delivery.
B. Applying pressure to the client's fundus is not part of the McRoberts maneuver. Fundal pressure may be used in other techniques to manage shoulder dystocia, such as the Rubin maneuver or Woods' screw maneuver.
C. Pressing firmly on the client's suprapubic area is not part of the McRoberts maneuver. This action may be performed in conjunction with other maneuvers to help dislodge the impacted shoulder.
D. Moving the client onto their hands and knees is not part of the McRoberts maneuver. This position, known as the Gaskin maneuver, may be used as an alternative maneuver to alleviate shoulder dystocia by changing the orientation of the pelvis.
Correct Answer is A
Explanation
Rationale:
A. When teaching parents about the Plastibell circumcision technique, it's important to explain that a yellow exudate (sometimes referred to as granulation tissue) will typically form at the surgical site within 24 hours after the procedure. This is a normal part of the healing process and should not be a cause for concern.
B. The end of the penis will likely get red, then develop a yellow discharge, and finally scab over, “like a skinned knee.” This is the normal healing process and will progress over the 7-14 days that the Plastibell Ring stays on. The correct size Plastibell Ring is secured with a string and the excess skin trimmed. The skin that overlaps the ring will turn dark “like the umbilical cord” before the ring falls off at 7-14 days.
C. The Plastibell is typically left in place for several days, not removed 4 hours after the procedure.
D. Ensuring the newborn's diaper is snug may help keep the Plastibell in place, but it is not the most crucial aspect of care related to the circumcision technique.
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