A nurse is caring for a newborn who is experiencing neonatal abstinence syndrome. Which of the following actions should the nurse take?

Provide frequent stimulation for the newborn.

Encourage frequent eye contact with the newborn during feedings.

Decrease the lighting levels in the nursery.

Wrap the newborn loosely in a blanket

Answer and Explanation

The Correct Answer is C

A. Provide frequent stimulation for the newborn. Excessive stimulation can worsen symptoms in newborns with neonatal abstinence syndrome (NAS), including irritability, tremors, and difficulty sleeping. These infants need a calm, low-stimulation environment to reduce neurologic stress.
B. Encourage frequent eye contact with the newborn during feedings. While bonding is important, prolonged or forced eye contact can overstimulate a newborn with NAS. These infants often have difficulty regulating sensory input and may become more irritable with excessive interaction.
C. Decrease the lighting levels in the nursery. A dim, quiet environment helps soothe infants experiencing NAS. Reducing lighting can minimize sensory overload, promote rest, and support neurologic regulation during withdrawal.
D. Wrap the newborn loosely in a blanket. Loose wrapping does not provide the security and containment that helps calm an overstimulated infant. Instead, swaddling the newborn snugly can reduce tremors, promote sleep, and offer comfort during withdrawal symptoms.

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Correct Answer is B

Explanation

A. Perform the Credé’s maneuver. This technique, involving manual pressure on the bladder, is used to promote urination in clients with bladder retention. It is not appropriate for a client with a catheter and continuous bladder irrigation in place.
B. Maintain the irrigation solution rate. Pink-tinged urine is an expected finding 4 hours after a TURP as minor bleeding can occur. There is no need to adjust the irrigation rate unless clots form or the urine becomes bright red or obstructed.
C. Warm the irrigation solution. Warming the solution is not a standard intervention and does not directly manage postoperative bleeding or pink urine. Room temperature solution is typically used unless otherwise specified by the provider.
D. Replace the indwelling urinary catheter. There is no indication the catheter is malfunctioning or obstructed. Pink urine alone does not warrant replacement, and unnecessary catheter changes can increase infection risk.

A. Match the client's blood type with the type and cross match specimen. B. Confirm the provider's prescription matches the number on the blood component. C. Ask the client to state his blood type and the date of the blood donation. D. Ensure that the client's identification band matches the number on the blood unit.

Correct Answer is D

Explanation

A. Match the client's blood type with the type and cross match specimen. While type and crossmatch are important for allogeneic transfusions, an autologous transfusion uses the client’s own previously donated blood, so this is not the primary method for identification.
B. Confirm the provider's prescription matches the number on the blood component. Although important, this step alone does not verify the client’s identity. The nurse must also confirm the blood unit matches the correct client.
C. Ask the client to state his blood type and the date of the blood donation. Client recall is not a reliable form of identification for transfusion safety, as it is prone to error or misunderstanding.
D. Ensure that the client's identification band matches the number on the blood unit. This is the correct and safest method to confirm identity before administering an autologous blood product. It ensures the blood product is matched to the correct patient.

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A nurse is caring for a newborn who is experiencing neonatal abstinence syndrome. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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