A nurse is caring for a newborn who is 56 hours old.
Vital Signs: At 07:00: Awake, alert, and crying.
The color is pink with acrocyanosis.
The respiratory rate is 70/min with no retractions, grunting, or nasal flaring noted.
Jitteriness is noted in the hands.
At 07:20: Attempted to feed the newborn.
Poor feeding and poor suck were noted.
Loose stool was observed in the diaper, which was then changed.
Which of the following assessment findings is consistent with neonatal abstinence syndrome (NAS)?
Awake, alert, and crying
pink with acrocyanosis
A respiratory rate of 70/min
Jitteriness in the hands
The Correct Answer is D
Choice A rationale: An awake, alert, and crying newborn is a common observation and does not specifically indicate Neonatal Abstinence Syndrome (NAS). Newborns have varying sleep-wake cycles, and it’s normal for them to have periods of being awake and alert. Crying is also a normal behavior for newborns as it’s their primary means of communication. It could indicate a variety of needs such as hunger, the need for a diaper change, or just the need for comfort and contact. Therefore, while an excessively crying baby could potentially be a sign of discomfort or distress, it is
not specifically indicative of NAS.
Choice B rationale: The presence of acrocyanosis, which is the bluish color of the hands and feet, is a normal finding in the first 24 to 48 hours of life due to immature circulation. It’s not specifically associated with NAS. NAS is a group of problems that occur in a newborn who was exposed to addictive opiate drugs while in the mother’s womb. Acrocyanosis is generally not a symptom of NAS.
Choice C rationale: A respiratory rate of 70/min is higher than the normal range (30-60/min) for a newborn and could indicate respiratory distress. However, it’s not specifically indicative of NAS. There are many potential causes of tachypnea (increased respiratory rate) in a newborn, including transient tachypnea of the newborn (TTN), respiratory distress syndrome (RDS), pneumonia, meconium aspiration syndrome (MAS), and more. While infants with NAS may experience symptoms such as stuffy nose, sneezing, and rapid breathing, a high respiratory rate alone is not specifically indicative of NAS.
Choice D rationale: Jitteriness in the hands of a newborn can be a sign of Neonatal Abstinence Syndrome (NAS). NAS is a drug withdrawal syndrome in newborns that occurs primarily among opioid-exposed infants shortly after birth, often manifested by central nervous system irritability, autonomic overreactivity, and gastrointestinal tract dysfunction. Jitteriness or tremors, especially when disturbed, along with other signs such as high-pitched crying, poor feeding, and
loose stools, are more indicative of NAS.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
While male condoms are a popular method of contraception due to their accessibility and ease of use, they are not the most reliable method. They have a higher failure rate compared to other methods, particularly if not used correctly or consistently.
Choice B rationale
Oral contraceptives are more reliable than male condoms, but they require consistent daily use and can be affected by other factors such as certain medications or vomiting/diarrhea.
Choice C rationale
A diaphragm with spermicide is a barrier method of contraception that is less reliable than hormonal methods or intrauterine devices. It also requires correct placement and use with every act of intercourse.
Choice D rationale
An intrauterine device (IUD) is one of the most reliable methods of contraception. Once inserted by a healthcare provider, it provides long-term, reversible contraception without requiring daily adherence.
Correct Answer is C
Explanation
Choice A rationale
While congenital anomalies, growth restriction, and fetal distress during labor can occur in pregnancies, they are not directly associated with polyhydramnios. Polyhydramnios is a condition characterized by an excessive accumulation of amniotic fluid in the uterus during pregnancy.
Choice B rationale
Carrying more than one fetus can lead to a condition known as twin-to-twin transfusion syndrome, which can result in polyhydramnios in one twin and oligohydramnios in the other. However, carrying more than one fetus does not directly mean the mother will experience polyhydramnios.
Choice C rationale
Polyhydramnios is indeed characterized by an excessive amount of amniotic fluid present in the uterus during pregnancy. This can be due to various reasons such as fetal abnormalities, maternal diabetes, and others.
Choice D rationale
An elevated level of alpha-fetoprotein (AFP) in the amniotic fluid can be an indication of certain fetal abnormalities, but it is not a direct indicator of polyhydramnios.
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