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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

A is correct because ginger tea is an herbal remedy that has been shown to reduce nausea and vomiting in pregnancy.

B is incorrect because ginger tea does not have any effect on breast tenderness, which is a common symptom of pregnancy caused by hormonal changes.

C is incorrect because ginger tea does not have any effect on headaches, which can be caused by various factors such as dehydration, stress, or caffeine withdrawal in pregnancy.

D is incorrect because ginger tea does not have any effect on urinary frequency, which is a common symptom of pregnancy caused by increased blood volume and pressure on the bladder.

A. Document the client's refusal in the medical record B. Honor the client's decision to refuse the blood transfusion C. Explore the client's reasons for refusing the treatment D. Discuss the client's refusal with the provider

Correct Answer is C

Explanation

Explore the client's reasons for refusing the treatment.

A. Documenting the client's refusal in the medical record is an important action, but not the first one. The nurse should first try to understand the client's perspective and address any concerns or misconceptions they might have about the blood transfusion. This choice is incorrect.
B. Honoring the client's decision to refuse the blood transfusion is a respectful and ethical action, but not the first one. The nurse should first attempt to educate and persuade the client about the benefits and risks of the treatment, and respect their autonomy only after ensuring that they have made an informed decision. This choice is incorrect.
C. Exploring the client's reasons for refusing the treatment is the first action that the nurse should take. The nurse should use effective communication skills to elicit the client's beliefs, values, fears, and preferences regarding the blood transfusion, and provide factual and evidencebased information to address any knowledge gaps or misconceptions. The nurse should also assess the client's decision-making capacity and determine if they are competent to refuse the treatment. This choice is correct.
D. Discussing the client's refusal with the provider is an appropriate action, but not the first one. The nurse should first try to resolve the issue with the client directly, and involve the provider only if they are unable to do so or if there are legal or ethical implications that require further consultation. This choice is incorrect.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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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?