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?

Transient strabismus

Mottling

Respiratory rate of 70/min

Loose stools

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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Correct Answer is C

Explanation

Choice A rationale
A thick, white vaginal discharge is more commonly associated with a yeast infection, not trichomoniasis.
Choice B rationale
Vulva lesions are not a typical symptom of trichomoniasis. They can be associated with other conditions such as herpes.
Choice C rationale
Trichomoniasis is a sexually transmitted infection caused by a parasite. One of the common symptoms in women is a foul-smelling vaginal discharge, which can be clear, white, yellowish, or greenish.
Choice D rationale
While urinary frequency can occur with trichomoniasis, it is not as specific or common as malodorous discharge.

A. Inform the client that the law requires them to name the fetus B. Limit the amount of time the fetus is in the client’s room C. Instruct the client that an autopsy should be performed within 24 hours D. Provide the client with photos of the fetus.

Correct Answer is D

Explanation

Choice A rationale
Informing the client that the law requires them to name the fetus is not accurate. Laws vary by location, but most do not require parents to name a stillborn fetus. It is important to provide accurate information and support the parents in their decisions during this difficult time.
Choice B rationale
Limiting the amount of time the fetus is in the client’s room is not necessarily beneficial. Each family will have different needs and preferences when it comes to spending time with their stillborn baby. Some families may find comfort in holding and spending time with their baby, while others may prefer not to. The nurse should support the family’s decisions and provide compassionate care.
Choice C rationale
Instructing the client that an autopsy should be performed within 24 hours is not necessarily beneficial. The decision to perform an autopsy will depend on a variety of factors, including the parents’ wishes, the circumstances of the stillbirth, and local laws and regulations. It is important to provide the parents with information and support them in making this decision.
Choice D rationale
Providing the client with photos of the fetus can be a helpful part of the grieving process for some families. It allows them to remember their baby and can be a tangible reminder of the baby’s existence. However, this should be done based on the family’s wishes.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

“A nurse is caring for a patient who is at 20 weeks of gestation and has trichomoniasis. Which of the following findings should the nurse expect?”

Correct Answer is C

Explanation

A nurse is caring for a client immediately following the delivery of a stillborn fetus. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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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?