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A nurse is caring for a newborn who is 5 days old.

Exhibits
Which of the following actions should the nurse take? Select all that apply.

Instruct the parent to avoid eye contact with the newborn during feeding.

Weigh the newborn daily.

Plan to administer naloxone.

Instruct the parent to avoid breastfeeding

Maintain a low stimulation environment

Swaddle the newborn with flexed extremities.

Perform Ballard newborn screening each shift.

Answer and Explanation

Correct Answer : B,E,F

A. Instruct the parent to avoid eye contact with the newborn during feeding – This is not recommended. While overstimulation should be minimized, gentle eye contact and bonding are still encouraged during feeding to promote attachment.

B. Weigh the newborn daily – Weight loss and feeding difficulties are common in NAS. Daily weight monitoring is essential to evaluate nutritional status and fluid balance.

C. Plan to administer naloxone – Naloxone is contraindicated in opioid-exposed neonates because it can precipitate acute withdrawal and seizures.

D. Instruct the parent to avoid breastfeeding – Breastfeeding is generally encouraged unless the mother is using illicit substances or is HIV-positive. Methadone is not a contraindication for breastfeeding.

E. Maintain a low stimulation environment – NAS newborns are easily overstimulated. A quiet, dimly lit environment helps reduce symptoms like irritability and tremors.

F. Swaddle the newborn with flexed extremities – Swaddling provides comfort and containment, helping to reduce stress responses in NAS infants.

G. Perform Ballard newborn screening each shift – The Ballard score is used once to assess gestational age and is not repeated every shift.

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Correct Answer is D

Explanation

A. Assessing cervical dilation is contraindicated due to risk of worsening bleeding with abruptio placenta.
B. Vaginal swabs for ferning test are used to assess rupture of membranes, not abruptio placenta.
C. Administering oxytocin can increase uterine contractions and worsen placental separation, so it is contraindicated.
D. Monitoring fetal heart rate tracings is essential to assess fetal well-being in cases of abruptio placenta.

A. High-pitched crying B. Tachypneic respirations C. Body tremors D. Extreme lethargy E. Decreased reflexes

Correct Answer is ["A","B","C"]

Explanation

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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A nurse is caring for a newborn who is 5 days old. Exhibits Which of the following actions should the nurse take? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Explanation

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A nurse is caring for a newborn who is 5 days old.

Exhibits
Which of the following actions should the nurse take? Select all that apply.