A nurse is assessing a newborn who is 48 hours old and is experiencing opioid withdrawals. Which of the following findings should the nurse expect?

Hypotonicity.

Moderate tremors of the extremities.

Axillary temperature 36.1°C (96.9°F)

Excessive sleeping.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Hypotonicity, or decreased muscle tone, is not an expected finding in a newborn experiencing opioid withdrawals. Opioid withdrawal symptoms usually involve increased muscle tone and jitteriness.

Choice B rationale:

Moderate tremors of the extremities are an expected finding in a newborn experiencing opioid withdrawals. Neonates born to mothers who used opioids during pregnancy can exhibit tremors, irritability, and other withdrawal symptoms.

Choice C rationale:

An axillary temperature of 36.1°C (96.9°F) is within the normal range for a newborn's body temperature, so it is not directly related to opioid withdrawal and is not the expected finding in this situation.

Choice D rationale:

Excessive sleeping is not an expected finding in a newborn experiencing opioid withdrawals. Opioid withdrawal can lead to increased wakefulness and irritability in newborns.

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Correct Answer is C

Explanation

Choice A rationale:

Keeping the newborn dressed while receiving phototherapy is not recommended because the baby's skin needs to be exposed to the light to effectively treat hyperbilirubinemia. Direct exposure to light helps break down the excess bilirubin in the baby's blood, leading to its excretion.

Choice B rationale:

Applying lotion to the skin twice daily is contraindicated during phototherapy. Lotions and creams can block the light from reaching the skin and hinder the therapeutic effects of the phototherapy. The baby's skin should remain exposed to the light for optimal treatment.

Choice C rationale:

Maintaining an eye mask over the newborn's eyes is essential during phototherapy. The eyes are sensitive to light, and prolonged exposure to the phototherapy light can lead to eye damage. Using an eye mask protects the baby's eyes while allowing the rest of the body to receive the necessary light treatment.

Choice D rationale:

Maintaining the phototherapy during blood draws is crucial to ensure continuous treatment of hyperbilirubinemia. Interrupting the phototherapy during blood draws might result in the rebound of bilirubin levels, which can be harmful to the baby.

A. "I will leave the diaphragm in place for 4 hours following intercourse.” B. "I will remove the diaphragm by catching the rim below the dome with my forefinger.” C. "I will place a thin layer of mineral oil on the diaphragm once per week.” D. "I will place 2 teaspoons of spermicide on the inside of the diaphragm before inserting it.”

Correct Answer is D

Explanation

Choice A rationale:

Leaving the diaphragm in place for 4 hours following intercourse is incorrect. The diaphragm should be left in place for at least 6 hours after intercourse to ensure effectiveness in preventing pregnancy.

Choice B rationale:

Removing the diaphragm by catching the rim below the dome with the forefinger is incorrect. The diaphragm should be removed by hooking the finger behind the rim to avoid damaging the dome and ensure proper removal.

Choice C rationale:

Placing a thin layer of mineral oil on the diaphragm once per week is incorrect. Mineral oil can weaken latex diaphragms, reducing their effectiveness. Water-based lubricants are recommended for use with diaphragms.

Choice D rationale:

Placing 2 teaspoons of spermicide on the inside of the diaphragm before insertion is the correct technique. Spermicide helps to immobilize and kill sperm, enhancing the contraceptive effect of the diaphragm.

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A nurse is assessing a newborn who is 48 hours old and is experiencing opioid withdrawals. Which of the following findings should the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a newborn with hyperbilirubinemia. Which of the following interventions should be taken during phototherapy?

Correct Answer is C

Explanation

A nurse is teaching a client who is to start using a diaphragm for contraception. Which of the following client statements indicates an understanding of the teaching?

Correct Answer is D

Explanation

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