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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

Answer and Explanation

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

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Free Nursing Study Resources

Correct Answer is C

Explanation

Rationale:

A. Administering methylergonovine is not appropriate for a fourth-degree perineal laceration.

Methylergonovine is typically used to prevent or treat postpartum hemorrhage by promoting uterine contractions.

B. Applying povidone-iodine to the client's perineum is not indicated for the management of a perineal laceration. Povidone-iodine is an antiseptic solution used for wound cleansing, but it may be too harsh for the perineal area.

C. Providing the client with a cool sitz bath is appropriate for managing discomfort and promoting healing after a fourth-degree perineal laceration. A sitz bath helps to soothe the perineal area and reduces inflammation.

D. Applying a moist, warm compress to the perineum is not recommended for a fourth-degree perineal laceration, as it may increase the risk of infection and discomfort.

A. Have the client limit the length of breastfeeding to 5 min per breast. B. Instruct the client to wait 4 hr between daytime feedings. C. Offer supplemental formula between the newborn's feedings. D. Assess the newborn's latch while breastfeeding.

Correct Answer is D

Explanation

Rationale:

A. Limiting the length of breastfeeding to 5 minutes per breast is not recommended and may lead to inadequate milk transfer and supply issues.

B. Instructing the client to wait 4 hours between daytime feedings may result in insufficient milk intake for the newborn and could impact breastfeeding success.

C. Offering supplemental formula between feedings may interfere with establishing breastfeeding and could decrease the client's milk supply.

D. Assessing the newborn's latch while breastfeeding is the appropriate action for addressing sore nipples. Poor latch is a common cause of nipple soreness in breastfeeding mothers. Ensuring the newborn has a proper latch can help alleviate discomfort and prevent further nipple trauma.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is 12 hr postpartum and has a fourth-degree laceration of the perineum. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is caring for a client who is 1 day postpartum and breastfeeding her newborn. The client reports sore nipples. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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