A nurse is caring for an infant with Neonatal Abstinence Syndrome (NAS). Which of the following statements concerning NAS is false.
Incessant crying is a common assessment finding.
Treatment with medications for withdrawal depends on the substance.
Appropriate nursing care is to cluster care and to assist with feeding difficulties.
Urine and meconium drug screening is not indicated for these infants.
The Correct Answer is D
Choice A rationale
Incessant, high-pitched crying is a hallmark symptom of central nervous system (CNS) hyperirritability observed in infants with Neonatal Abstinence Syndrome (NAS). This persistent distress is due to the lack of the depressant drug effects in the newborn's system, leading to uncoordinated and exaggerated responses to stimuli. The infant's state is often difficult to soothe, contributing to parental stress and feeding difficulties.
Choice B rationale
Pharmacological treatment for significant opioid-related withdrawal (NAS) often involves the use of opioids, such as morphine or methadone, to manage severe symptoms, allowing the infant to be weaned gradually from the dependence. For withdrawal from other substances, such as selective serotonin reuptake inhibitors, supportive care is primarily used, while for alcohol, benzodiazepines might be used, reflecting substance-specific treatment strategies.
Choice C rationale
Clustering care minimizes external stimulation and provides periods of uninterrupted rest, which is essential for managing the CNS hyperirritability common in NAS. Furthermore, feeding difficulties are frequent due to poor suck-swallow coordination, tremors, and gastric issues, so dedicated, supportive feeding assistance is a crucial component of the nursing care plan.
Choice D rationale
Urine and meconium drug screening is absolutely indicated and is crucial for identifying the specific substances the infant was exposed to prenatally. This information is vital for diagnosis, determining the severity of withdrawal (using tools like the Finnegan score), guiding the appropriate pharmacological and non-pharmacological treatment plan, and initiating social services involvement. —.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Bone marrow aspiration and biopsy is the definitive diagnostic test for leukemia. This procedure involves extracting a small sample of the bone marrow, typically from the iliac crest in children, to analyze the type and percentage of immature blood cells (blasts) that characterize leukemia, thus confirming the diagnosis accurately.
Choice B rationale
A Computed Tomography (CT) scan uses X-rays to create cross-sectional images of the body. While useful for assessing solid tumors or detecting intracranial or chest disease complications of leukemia, it is not the primary or definitive diagnostic test for the condition itself, which is a cancer of the blood and bone marrow.
Choice C rationale
A Complete Blood Cell Count (CBC) is a crucial screening tool that often suggests the presence of leukemia by revealing abnormal white blood cell counts (often high or very low) and possibly anemia or thrombocytopenia. However, the CBC alone cannot confirm the diagnosis; it only indicates the need for definitive testing.
Choice D rationale
A Lumbar Puncture (spinal tap) is performed to collect cerebrospinal fluid (CSF) to check for the presence of leukemic cells that may have infiltrated the central nervous system, which is essential for staging and treatment planning, but it does not confirm the initial diagnosis of leukemia in the bone marrow.
Correct Answer is D
Explanation
Choice A rationale
Seizures, while common in children with various neurological disorders, including those with intellectual disability, are not the most sensitive or specific indicator for intellectual disability itself. Seizure disorders can result from many causes, such as structural brain abnormalities, infections, or genetic conditions, and their presence alone does not reliably quantify or define the degree of cognitive impairment.
Choice B rationale
Preterm birth, especially very low birth weight, is a significant risk factor for developmental delays and intellectual disability due to potential damage to the developing brain; however, many preterm infants develop normally. It is an antecedent risk, not a direct measure or the most sensitive clinical indicator of existing intellectual functional limitations.
Choice C rationale
Vision deficits are sensory impairments that can coexist with intellectual disability or be caused by related syndromes, but they are separate developmental domains. A vision deficit does not directly reflect the child's adaptive behavior or intellectual functioning, which are the core components used to define intellectual disability.
Choice D rationale
Language delay is often one of the earliest and most observable indicators of intellectual disability in children, as communication skills are integral to cognitive development and adaptive functioning. Delays in acquiring language milestones, such as using first words or combining words, frequently correlate strongly with underlying cognitive limitations.
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