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A nurse is assisting with the care of a 1-month-old infant who has neonatal abstinence syndrome and is receiving phenobarbital. Which of the following findings indicates to the nurse that the medication has had a therapeutic effect?

Improved feedings

Restored surfactant

Decreased CNS irritability

Decreased excoriation

Answer and Explanation

The Correct Answer is C

Choice A reason:

Improved feedings can be a positive sign, but it may not directly indicate the therapeutic effect of phenobarbital.

Choice B reason:

Restored surfactant is not directly related to the action of phenobarbital, which is used to manage symptoms of neonatal abstinence syndrome.

Choice C reason:

Phenobarbital is a medication that can help alleviate CNS irritability in infants with neonatal abstinence syndrome. Therefore, a decrease in CNS irritability indicates a therapeutic effect of the medication.

Choice D reason:

Decreased excoriation is not a primary effect of phenobarbital. This medication primarily addresses CNS symptoms associated with neonatal abstinence syndrome.

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Correct Answer is D

Explanation

Choice A reason:

Taping the wire to the palm of the hand can be uncomfortable for the child and may interfere with blood flow.

Choice B reason:

Warming the skin prior to probe placement is not a standard practice for pulse oximetry monitoring.

Choice C reason:

Applying the sensor to the index fingernail is not a recommended site for pulse oximetry monitoring in children.

Choice D reason:

Repositioning the probe every 2 hours helps to prevent skin breakdown and ensures accurate readings over time. This is a standard practice in pulse oximetry monitoring.

A. Ensure the child's safety. B. Tell the child they are not at fault. C. Document the location of the child’s injuries D. Notify local law enforcement.

Correct Answer is A

Explanation

Choice A reason:

Ensuring the child's safety is the top priority. If the child is in immediate danger, steps must be taken to protect them.

Choice B reason:

While providing emotional support to the child is important, ensuring their physical safety takes precedence.

Choice C reason:

Documenting injuries is important for a comprehensive assessment and for legal purposes, but it should follow ensuring the child's immediate safety.

Choice D reason:

Notifying law enforcement may be necessary, but ensuring the child's immediate safety comes first.

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A nurse is assisting with the care of a 1-month-old infant who has neonatal abstinence syndrome and is receiving phenobarbital. Which of the following findings indicates to the nurse that the medication has had a therapeutic effect?

Nursing Test Bank

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