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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A rationale:

This statement is incorrect. The client should receive Rh(D) immune globulin (RhoGAM) if they are Rh-negative and their partner's Rh status is unknown or Rh-positive. This prevents the development of Rh antibodies in the mother's blood, which could be harmful in future pregnancies if the baby is Rh-positive.

Choice B rationale:

This statement is incorrect. Rh(D) immune globulin is administered to an Rh-negative mother within 72 hours after delivery if the baby is Rh-positive. This is done to prevent the mother from developing Rh antibodies that could affect subsequent pregnancies.

Choice C rationale:

This statement is incorrect. There is no restriction on receiving other immunizations after receiving Rh(D) immune globulin. The shot only protects against Rh incompatibility and does not interfere with other immunizations.

Choice D rationale:

This statement is correct. Rh(D) immune globulin can be given after birth to an Rh-negative mother with an Rh-positive baby. This helps protect the mother's future pregnancies from the potential harmful effects of Rh incompatibility.

A. "I will notify my provider if I experience chest pain, shortness of breath, or leg pain.” B. "I will use an alternative form of birth control if I miss three pills.” C. "If I miss three pills, I will double up each day until back on schedule.” D. "I will have to have follow-up appointments with my provider while taking this medication.”

Correct Answer is C

Explanation

Choice A rationale:

This statement indicates that the client understands the potential side effects of oral contraception and the importance of reporting them promptly to their healthcare provider. Chest pain, shortness of breath, or leg pain can be indicative of serious complications, such as blood clots, which can occur with oral contraceptive use.

Choice B rationale:

This statement demonstrates the client's understanding of what to do if they miss three pills. Using an alternative form of birth control is a responsible action to prevent unintended pregnancies, as missing multiple pills can decrease contraceptive effectiveness.

Choice C rationale:

This statement reveals a misunderstanding of the appropriate action to take if the client misses three pills. Instead of doubling up, the client should be instructed to take the missed pill as soon as they remember and continue taking the pills as usual. Doubling up can increase the risk of side effects and won't necessarily prevent pregnancy.

Choice D rationale:

This statement indicates that the client comprehends the need for follow-up appointments while on oral contraception. Regular follow-ups are essential to monitor the client's health, address any concerns, and ensure the effectiveness of the chosen contraceptive method.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a pregnant client who is Rh-negative about Rh(D) immune globulin. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is D

Explanation

A nurse has provided education to a client who has been prescribed oral contraception. Which of the following client statements indicates a need for further education?

Correct Answer is C

Explanation

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