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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

A: Introducing fruit juice at 4 months old is not recommended because infants' digestive systems are not yet ready for such foods, and it can increase the risk of tooth decay and obesity.

B: Introducing eggs at 6 months could be appropriate; however, it is not the best choice as it does not reflect the gradual introduction of new foods one at a time, which is essential to monitor for any allergic reactions or food intolerances.

C: Offering cereal with a percent of milk is not advisable for a 4-month-old infant as cow's milk should not be introduced until the child is at least 12 months old due to the risk of iron deficiency and potential allergies.

D: Offering a new food every 7 days is the correct approach as it allows parents to introduce new foods gradually and monitor the infant for any adverse reactions or allergies, which aligns with the guidelines provided by health authorities.

A. Client's current blood glucose is 220 mg/dL B. Client is exhibiting Kussmaul respirations C. Client reports vomiting once that day D. Client reports frequent urination

Correct Answer is B

Explanation

Choice A reason:

A blood glucose level of 220 mg/dL is elevated and should be addressed, but it may not be an immediate priority compared to the presence of Kussmaul respirations.

Choice B reason.

Correct. Kussmaul respirations are a sign of diabetic ketoacidosis (DKA), a severe complication of diabetes. This requires immediate attention and intervention.

Choice C reason:

Vomiting is a concerning symptom, but it may not be as immediately life-threatening as Kussmaul respirations.

Choice D reason:

Frequent urination is a common symptom of diabetes, but it may not require immediate intervention unless it is accompanied by other severe symptoms.

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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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