A nurse is caring for an infant who has signs of neonatal abstinence syndrome. Which of the following actions should the nurse take?
Provide a stimulating environment
Monitor blood glucose level every hour
Initiate seizure precautions
Place the infant on his back with legs extended
The Correct Answer is C
Choice A rationale
Providing a stimulating environment is not recommended for infants with neonatal abstinence syndrome (NAS). These infants often have a heightened response to stimuli, and a calm, quiet environment is usually more beneficial.
Choice B rationale
While it is important to monitor the infant’s overall health, there is no specific need to monitor blood glucose level every hour in infants with NAS unless there is a separate medical indication.
Choice C rationale
Initiating seizure precautions is an appropriate action for a nurse caring for an infant with signs of NAS5. Infants with NAS are at risk for seizures, so nurses should be prepared to manage this potential complication.
Choice D rationale
Placing the infant on his back with legs extended is not recommended. Infants with NAS often have increased muscle tone and may be uncomfortable in this position.
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Related Questions
Correct Answer is D
Explanation
Choice A rationale
Gestational diabetes mellitus is not a contraindication for a contraction stress test. This condition affects how the mother’s body uses glucose (sugar) during pregnancy, but it does not interfere with the ability to perform a contraction stress test.
Choice B rationale
A previous stillbirth is not a contraindication for a contraction stress test. A stillbirth refers to the loss of a baby after 20 weeks of pregnancy. While this is a significant event, it does not prevent the mother from undergoing a contraction stress test in a subsequent pregnancy.
Choice C rationale
A nonreactive nonstress test is not a contraindication for a contraction stress test. A nonreactive nonstress test indicates that the baby’s heart rate does not speed up (or “react”) as it should when the baby moves. However, this result does not prevent the mother from undergoing a contraction stress test.
Choice D rationale
A previous classical incision is a contraindication for a contraction stress test. A classical incision refers to a vertical cut in the upper part of the uterus, which is typically used during a cesarean section. This type of incision increases the risk of uterine rupture, which can be life- threatening for both the mother and the baby. Therefore, a contraction stress test, which induces contractions, should not be performed due to the risk of uterine rupture.
Correct Answer is B
Explanation
Choice A rationale
A score of 9 on the Edinburgh Postnatal Depression Screen (EPDS) on postpartum day 2 is below the clinical cutoff score of 10, which is used to distinguish health controls versus possible depression. Therefore, this score would not indicate a high risk of developing a depressive disorder.
Choice B rationale
A score of 11 on the EPDS on postpartum day 30 is above the clinical cutoff score of 1034. This score indicates a high risk of developing a depressive disorder. Therefore, further assessment and possible intervention would be necessary.
Choice C rationale
While discharge teaching is an important aspect of postpartum care, it does not provide information about the client’s risk of developing postpartum depression. Therefore, this choice does not answer the question.
Choice D rationale
A follow-up appointment with a provider in 4 weeks is a standard part of postpartum care, but it does not provide information about the client’s risk of developing postpartum depression.
Therefore, this choice does not answer the question.
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