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A nurse is assessing a term newborn who is 48 hours old.

The mother has a history of opioid use during pregnancy and was prescribed methadone.

Based on the findings 24 hours later, how should the nurse interpret the findings?

A.

Transient strabismus

B.

Mottling

C.

Respiratory rate of 70/min

D.

Loose stools

E.

Regurgitation

Answer and Explanation

The Correct Answer is C

Choice A rationale
Transient strabismus, or temporary misalignment of the eyes, is not typically a symptom observed in newborns exposed to opioids during pregnancy.
Choice B rationale
Mottling, or patchy skin color, is a common physical characteristic in newborns and is not specifically associated with opioid exposure during pregnancy.
Choice C rationale
A respiratory rate of 70/min is significantly higher than the normal range for a newborn, which is typically between 30 and 60 breaths per minute. This could be a sign of neonatal abstinence syndrome (NAS), a group of conditions caused by withdrawal from certain drugs that the newborn was exposed to in the womb.
Choice D rationale
Loose stools are not typically associated with opioid exposure during pregnancy.
Choice E rationale
Regurgitation, or spitting up, is common in newborns and is not specifically associated with opioid exposure during pregnancy.
 


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Related Questions

Correct Answer is C

Explanation

Choice A rationale
Neonatal abstinence syndrome (NAS) is a group of problems that occur in a newborn who was exposed to addictive opiate drugs while in the mother’s womb. Diminished deep tendon reflexes are not typically associated with NAS3.
Choice B rationale
The Moro reflex, also known as the startle reflex, is one of the many reflexes that babies are born with. An absent Moro reflex is not typically associated with NAS3.
Choice C rationale
Excessive crying is a common symptom of NAS. Babies with NAS are often irritable and hard to comfort.
Choice D rationale
Decreased muscle tone is not typically associated with NAS. In fact, babies with NAS often have increased muscle tone, which can result in tight muscle tone and difficulty relaxing muscles.

Correct Answer is A

Explanation

Choice A rationale
The instillation of antibiotic ophthalmic ointment is delayed to facilitate bonding between the newborn and the parent. Immediate skin-to-skin contact between the newborn and the parent has been shown to have several benefits, including stabilizing the newborn’s heart rate, temperature, and breathing, stimulating digestion, helping the newborn to sleep, promoting weight gain, and aiding in maternal attachment.
Choice B rationale
The newborn’s weight does not affect the timing of the instillation of antibiotic ophthalmic ointment.
Choice C rationale
Manifestations of infection in the newborn’s eyes would not be immediately apparent following birth, so this would not be a reason to delay the instillation of antibiotic ophthalmic ointment.
Choice D rationale
The mode of delivery, whether vaginal or cesarean, does not affect the timing of the instillation of antibiotic ophthalmic ointment.

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