A nurse is caring for a newborn who is 5 days old.
Medical History
History of maternal opioid use prior to pregnancy and prescribed methadone use during pregnancy. Maternal and neonatal positive urine drug screens for methadone. Newborn is exhibiting clinical findings of neonatal abstinence syndrome (NAS).
Which of the following actions should the nurse take? Select all that apply.
Maintain a low stimulation environment.
Plan to administer naloxone.
Instruct the parent to avoid breastfeeding
Instruct the parent to avoid eye contact with the newborn during feeding
Perform Ballard newborn screening each shift.
Weigh the newborn daily.
Swaddle the newborn with flexed extremities
Correct Answer : A,C,E,F,G
Rationale:
A. Newborns with neonatal abstinence syndrome (NAS) are often irritable and hypersensitive to stimuli. Keeping the environment calm and quiet can help minimize their discomfort.
B. Naloxone is not routinely used in the management of NAS unless there is evidence of severe respiratory depression or opioid overdose, which is not indicated in this scenario.
C. Maternal opioid use and positive urine drug screens for methadone may contraindicate breastfeeding due to the potential transmission of opioids to the infant through breast milk. It's essential to consult with healthcare providers regarding the safest feeding option for the newborn.
D. Eye contact during feeding is essential for bonding between the parent and the newborn and should not be discouraged unless medically necessary.
E. Ballard newborn screening helps assess the newborn's gestational age and guide appropriate care for neonates with NAS, as they may require specialized management.
F. Daily weighing helps monitor the newborn's hydration status and overall well-being, which is crucial in managing NAS and ensuring adequate nutrition.
G. Swaddling can provide comfort to newborns with NAS by mimicking the womb environment and reducing their agitation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. Using Naegle’s rule, May 3rd isn’t the correct answer
B. Using Naegle’s rule, May 20th isn’t the correct answer
C. Using Naegle’s rule, May 13th isn’t the correct answer
D. This is the correct answer Using Nägele's Rule:
1. Determine the first day of the last menstrual period (LMP): August 10.
2. Subtract 3 months: August - 3 months = May.
3. Add 7 days: May 10 + 7 days = May 17.
Correct Answer is B
Explanation
Rationale:
A. Epigastric discomfort is not typically associated with pyelonephritis. It may be a symptom of other conditions such as gastrointestinal issues or preeclampsia.
B. Flank pain is a common manifestation of pyelonephritis, which is an infection of the kidneys.
Clients with pyelonephritis often experience pain in the flank area, which is located between the lower ribs and the pelvis, on one or both sides of the body.
C. A temperature of 37.7°C (99.8°F) may indicate a low-grade fever, which can be present in pyelonephritis due to the body's immune response to infection.
D. Abdominal cramping may occur with various conditions during pregnancy but is not specific to pyelonephritis.
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