A nurse is performing a physical assessment of a newborn whose mother used cocaine throughout the pregnancy.
Which of the following findings should the nurse expect?
Irritability.
Hypotonicity.
Decreased auditory startle response.
Increased head circumference.
The Correct Answer is A
Choice A rationale:
Irritability is a common withdrawal symptom in newborns exposed to cocaine during pregnancy. Cocaine exposure can lead to irritability, restlessness, and difficulty in consoling the newborn.
Choice B rationale:
Hypotonicity, or decreased muscle tone, is not a common finding associated with cocaine exposure in newborns. Cocaine exposure more commonly results in hypertonicity, where the muscles are tense and rigid.
Choice C rationale:
Decreased auditory startle response is not a typical finding associated with cocaine exposure. Newborns exposed to cocaine may have an exaggerated startle response, which is the opposite of the expected finding in this case.
Choice D rationale:
Increased head circumference is not a characteristic finding associated with cocaine exposure. Cocaine exposure is more likely to cause growth restriction, low birth weight, and microcephaly (small head size) in newborns.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
This statement implies that the nurse attempted the dressing change but was unsuccessful. However, the information about the dressing not being soiled is irrelevant to the incident report. The key issue is the omission of the prescribed procedure.
Choice B rationale:
This statement acknowledges the omission but lacks specificity. It does not state the nature of the omission or the potential consequences, making it less informative for future prevention strategies.
Choice C rationale:
This statement clearly and concisely states the situation, indicating that the prescribed dressing change was omitted. It provides essential information for understanding what happened, allowing for appropriate investigation and preventive measures.
Choice D rationale:
This statement confirms the completion of the incident report but does not provide details about the incident itself. Without specific information about the omission, this statement is insufficient for understanding the nature of the error and implementing preventive actions.
Correct Answer is C
Explanation
Choice A rationale:
Massaging the legs before applying the stockings is not advisable. Vigorous massage can dislodge clots in patients with DVT, leading to serious complications like pulmonary embolism. It is essential to handle the legs gently and follow the proper procedure for applying antiembolitic stockings.
Choice B rationale:
Folding the stockings at the top if they are too long is not recommended. Altering the stockings in this way can create uneven pressure, reducing their effectiveness in preventing DVT. It is crucial to choose the correct size of stockings to ensure proper compression and prevention of complications.
Choice C rationale:
Measuring the legs with a tape measure to determine the stocking size is the correct action. Proper sizing is essential to ensure the stockings fit the patient correctly and provide the appropriate level of compression. Ill-fitting stockings can be ineffective and may even cause harm, such as skin abrasions or impeded circulation.
Choice D rationale:
Removing the stockings every 24 hours is unnecessary unless there is a specific medical indication to do so. Continuous wear of antiembolitic stockings is generally recommended to provide consistent compression and prevent deep-vein thrombosis (DVT)
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