A nurse is caring for a newborn who is 72 hr old.
Vital signs
0900:
- Heart rate 160/min
- Respiratory rate 80/min
- Temperature 38.1° C (100.6° F)
- Oxygen saturation 97%
1000:
- Heart rate 167/min
- Respiratory rate 72/min
- Temperature 38°C (100.4°F)
- Oxygen saturation 97%
Medical History
0900:
A term newborn 37 weeks of gestation is admitted to the newborn nursery following a precipitous vaginal birth. Birthing parent has a history of heroin use during pregnancy and prenatal care beginning at 34 weeks of gestation. Birthing parent and newborn drug screens positive for heroin.
The nurse is planning to contact the provider regarding the newborn's status. Which of the following prescriptions should the nurse anticipate? Select the 3 interventions the nurse should anticipate.
Administer oral morphine.
Swaddle the newborn.
Administer naloxone for NAS scores greater than 24.
Encourage the birthing parent to breastfeed.
Continue NAS scoring as prescribed
Correct Answer : A,B,E
A. Administering oral morphine is anticipated because it is used to manage withdrawal symptoms in newborns with Neonatal Abstinence Syndrome (NAS..
B. Swaddling is a non-pharmacological intervention that can provide comfort and reduce overstimulation.
C. Administering naloxone is not typically the first line of treatment for NAS and is used in cases of acute opioid overdose, which is not indicated by the information provided.
D. Encouraging the birthing parent to breastfeed may not be appropriate due to the presence of heroin in the system, which can be transmitted to the newborn through breast milk.
E. Continuing NAS scoring is essential to monitor the newborn's condition and response to treatment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. This statement is overly dismissive and does not provide the client with accurate information about herbal therapies. Herbal therapies can have benefits for some individuals, but their efficacy and safety can vary widely.
B. "Many herbal products have not undergone long-term testing for safety and efficacy." This statement provides important information to the client about the potential risks associated with herbal therapies. It emphasizes the need for caution and informed decision-making when considering their use.
C. This statement is premature and does not address the need for further assessment or consideration of potential risks and benefits before starting herbal therapies.
D. This statement is inaccurate, as herbal therapies can have side effects and interactions with medications. It does not adequately inform the client about the potential risks associated with herbal therapies.
Correct Answer is C
Explanation
Rationale:
A. "My child will take the enzymes 2 hours before meals.": Pancreatic enzymes should be taken with meals or snacks, not before.
B. "My child will take the enzymes to improve her metabolism.": While pancreatic enzymes help with digestion, their purpose is not to improve metabolism.
C. "My child will take the enzymes to help digest the fat in foods.": This statement accurately reflects the purpose of pancreatic enzymes in cystic fibrosis. These enzymes are necessary because individuals with cystic fibrosis often have pancreatic insufficiency, leading to difficulty digesting fats and certain nutrients in food.
D. "My child will take the enzymes following meals.": Pancreatic enzymes should be taken with meals or snacks, not after.
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