A nurse is assessing a newborn who was exposed to heroin during pregnancy. Which of the following findings should indicate to the nurse that the newborn is experiencing neonatal abstinence syndrome? (Select all that apply.)
High-pitched crying
Tachypneic respirations
Body tremors
Extreme lethargy
Decreased reflexes
Correct Answer : A,B,C
A. High-pitched, excessive crying is a common sign of neonatal abstinence syndrome (NAS).
B. Tachypnea (rapid breathing) is a typical respiratory symptom of NAS.
C. Body tremors and jitteriness are classic signs of withdrawal in newborns.
D. Newborns with NAS typically exhibit hyperactivity, not extreme lethargy.
E. Reflexes are usually increased (hyperactive), not decreased, in NAS.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D"]
Explanation
A. Double-flush the toilet with the lid closed – Methotrexate is a hazardous medication that is excreted in body fluids. The client should be instructed to double-flush the toilet with the lid closed for 48 hours to prevent exposure to others.
B. Avoid sexual intercourse until the β-hCG level is undetectable – This reduces the risk of rupture or bleeding and prevents confusion with another pregnancy. Abstinence is recommended until the ectopic pregnancy is fully resolved.
C. Take aspirin as needed for pain – Aspirin is contraindicated as it increases the risk of bleeding and can interact adversely with methotrexate, enhancing toxicity.
D. Avoid exposure to the sun – Methotrexate can cause photosensitivity, and the client should use sunscreen and protective clothing when outdoors.
E. Expect a transient fever and chills – Fever and chills are not expected side effects of methotrexate. These symptoms may indicate infection or rupture and should be reported immediately.
Correct Answer is B
Explanation
A. Nausea is a common and generally mild side effect of oral contraceptives and does not typically require immediate medical attention.
B. Persistent headaches may indicate an increased risk of stroke or hypertension, especially in clients with other risk factors. This could be a sign of a serious adverse effect and should be reported to the provider immediately.
C. Breast tenderness is a common and usually benign side effect of hormonal contraceptives.
D. Abdominal bloating may occur but is not typically dangerous or an urgent concern.
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