A nurse is assessing a newborn who is 48 hr old and has a maternal history of methadone use during pregnancy. Which of the following manifestations should the nurse identify as an indication of neonatal abstinence syndrome?
Hyporeactivity.
Excessive high-pitched cry.
Acrocyanosis.
Respiratory rate of 50/min.
The Correct Answer is B
Choice A rationale:
Hyporeactivity, or reduced responsiveness to stimuli, is not typically associated with neonatal abstinence syndrome (NAS) NAS is characterized by increased irritability and not reduced activity.
Choice B rationale:
An excessive high-pitched cry is a common manifestation of neonatal abstinence syndrome. Infants exposed to substances like methadone during pregnancy may experience heightened sensitivity and exhibit a high-pitched cry as a sign of withdrawal.
Choice C rationale:
Acrocyanosis, a bluish discoloration of the hands and feet, is not a specific indicator of neonatal abstinence syndrome. It is a common finding in newborns and often resolves on its own.
Choice D rationale:
A respiratory rate of 50/min is within the normal range for a newborn. It is not an indication of neonatal abstinence syndrome.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Raloxifene is not used to treat migraines. It is a selective estrogen receptor modulator (SERM) that primarily acts on bone tissues, estrogen receptors, and has anti-estrogenic effects in the breast, which may reduce the risk of breast cancer.
Choice B rationale:
Raloxifene is not used to treat hypertension (high blood pressure) It is primarily indicated for the prevention and treatment of osteoporosis in postmenopausal women.
Choice C rationale:
This is the correct choice. Raloxifene is indicated for the treatment and prevention of osteoporosis in postmenopausal women. It helps increase bone density and reduces the risk of fractures associated with osteoporosis.
Choice D rationale:
Raloxifene is not used to treat heart disease. While it may have some cardiovascular benefits due to its effects on cholesterol levels, it is not a primary medication for heart disease management.
Correct Answer is A
Explanation
Choice A rationale:
The priority nursing action when the fetal heart rate shows a deceleration after the contraction has started, with the lowest point occurring after the peak of the contraction, is to change the client's position. This deceleration pattern is called "late decelerations,” and it is typically associated with uteroplacental insufficiency, which can be caused by maternal hypotension or impaired blood flow to the placenta. Changing the client's position, such as moving the client to their side or repositioning them, can alleviate pressure on the vena cava and improve blood flow to the placenta, thus potentially resolving or minimizing the late decelerations.
Choice B rationale:
Inserting a scalp electrode (Choice B) is not the priority action in this situation. While a scalp electrode may be used to monitor the fetal heart rate more accurately and continuously, it is not the initial intervention for addressing late decelerations.
Choice C rationale:
Preparing for amnioinfusion (Choice C) may be considered if there are variable decelerations (caused by cord compression) present, but it is not the priority intervention for late decelerations.
Choice D rationale:
Documenting benign decelerations (Choice D) is not appropriate in this scenario since late decelerations are not considered benign and require immediate action.
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