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 ["B","C","D"]
Explanation
Choice A rationale
Resting in a recliner until the incision is healed is not recommended following a cesarean birth. It’s important for the client to gradually increase their activities and mobility to promote healing and prevent complications such as blood clots.
Choice B rationale
It’s crucial for the client to monitor their incision for signs of infection, such as increased redness, swelling, pain, or discharge. Therefore, calling the provider if there is discharge from the incision indicates understanding of the discharge instructions.
Choice C rationale
Resuming prenatal vitamins is often recommended after a cesarean birth to aid in recovery and support breastfeeding if the client chooses to breastfeed. Prenatal vitamins contain essential nutrients that can help the client heal and recover after surgery.
Choice D rationale
Unrelieved abdominal pain is not a normal part of recovery and could indicate a complication such as an infection or a problem with the incision. Therefore, the client should understand that they should not have unrelieved pain in their abdomen and should contact their provider if they do.
Correct Answer is C
Explanation
Choice A rationale
Monitoring axillary temperature is important for all newborns to prevent hypothermia. However, it is not the priority intervention for a newborn who is small for gestational age (SGA). These newborns are at a higher risk for hypoglycemia due to decreased stores of glycogen and a lower rate of gluconeogenesis.
Choice B rationale
Monitoring weight is important for all infants, and ongoing monitoring is important for infants who are SGA. However, it is not the priority intervention for this client at this time.
Choice C rationale
This is the correct answer. Newborns who are SGA are at a higher risk for hypoglycemia. Therefore, monitoring of blood glucose levels is a priority intervention.
Choice D rationale
Providing age-appropriate stimulation is important for all newborns. However, it is not the priority intervention for a newborn who is SGA2.
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