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. Decreased blood pressure: Menopause can be associated with fluctuations in blood pressure, but it is not typically characterized by decreased blood pressure.
B. Urinary retention: Urinary symptoms such as urgency, frequency, or stress incontinence may occur during menopause, but urinary retention is not a typical manifestation.
C. Dryness with intercourse: Vaginal dryness is a common symptom of menopause due to decreased estrogen levels, leading to changes in vaginal tissue and lubrication, which can cause discomfort during intercourse.
D. Elevation in body temperature above 37.8°C (100°F): Hot flashes are a hallmark symptom of menopause and are characterized by sudden feelings of heat, sweating, and flushing, but they do not typically cause a sustained elevation in body temperature.
Correct Answer is []
Explanation
Potential condition
Correct Answer: B. Meningocele
Rationale: Based on the provided physical examination details, the newborn is most likely experiencing a meningocele, which is indicated by the presence of a sac in the lumbar area. This condition is a type of neural tube defect where a sac of fluid comes through an opening in the baby's back. However, the absence of other neurological symptoms and the intactreflexes suggest that the condition has not severely affected the newborn's neurological functions.
Actions to Take (2)
Correct Answers: C, E
The two actions the nurse should take to address this condition include: applying a non-adhering sterile saline moist compress to the sac to prevent it from drying and to protect it from trauma, and educating the guardians about the condition, its implications, and the potential need for surgical intervention to repair the defect.
Parameters to monitor
Correct Answer: A, C
Rationale: The two parameters the nurse should monitor to assess the newborn's progress are the head circumference and serial head ultrasounds. Monitoring head circumference is crucial as an increase may indicate hydrocephalus, which can be associated with meningocele. Serial head ultrasounds are necessary to assess for any changes in the brain structure or development of hydrocephalus. These measures will help ensure that any complications are identified and managed promptly.
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