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 C
Explanation
Rationale:
A. While pelvic inflammatory disease (PID) can be associated with endometriosis, it is not a definitive indicator.
B. Abdominal bloating can occur in various conditions, but it is not specific to endometriosis.
C. Dysmenorrhea that is unresponsive to NSAIDs is a hallmark symptom of endometriosis. It often presents as severe menstrual cramps that are not relieved by over-the-counter pain
medications.
D. An atypical Papanicolaou smear does not directly relate to endometriosis; it may indicate other gynecological issues but is not specific to endometriosis.
Correct Answer is ["A","B","C","D"]
Explanation
A. "I'll make sure his diaper is loose in the front." This is correct because a loose diaper can prevent pressure on the circumcision site, reducing discomfort and the risk of disrupting the healing process.
B. "I'll expect the plastic ring to fall off by itself within a week." This statement is accurate as the Plastibell ring is designed to fall off on its own as the circumcision heals.
C. "I'll call the doctor if I see any bleeding." This is an appropriate action as bleeding can be a sign of a complication and should be assessed by a healthcare provider.
D. "I'll apply petroleum jelly to his penis with diaper changes." This is correct; applying petroleum jelly can help prevent the diaper from sticking to the circumcision site and aid in healing.
E. "I'll wash his penis with warm water and mild soap each day." This statement is not recommended with the Plastibell technique as it can disrupt the healing process. The site should be kept as dry as possible to allow the ring to fall off naturally.
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