A nurse is providing care for a newborn suspected of having neonatal abstinence syndrome. Which symptom would support this diagnosis?
Decreased muscle tone
Sleeps for 2 hours after feeding
Continuous high-pitched cry
Mild tremors when disturbed
The Correct Answer is C
Choice A rationale
Decreased muscle tone is not typically associated with neonatal abstinence syndrome (NAS). NAS is a condition that affects newborns who have been exposed to addictive opiate drugs while in the mother’s womb.
Choice B rationale
Sleeping for 2 hours after feeding is not a specific symptom of NAS. While changes in sleep patterns can occur in NAS, they are not definitive indicators of the condition.
Choice C rationale
A continuous high-pitched cry is a common symptom of NAS123. This is because the baby is going through withdrawal from the drugs they were exposed to in the womb.
Choice D rationale
Mild tremors when disturbed are indeed a symptom of NAS123. However, this symptom alone is not enough to diagnose NAS as it can be seen in other conditions as well.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
While an area of warmth can be a symptom of deep vein thrombosis (DVT), it is not the most specific or indicative symptom. DVT is a condition in which blood clots form in veins located deep inside the body, usually in the thigh or lower legs. The most common symptoms include swelling of the foot, ankle, or leg, usually on one side, cramping of the affected leg, severe leg pain, and skin on the affected area that is warmer than the skin on surrounding areas.
However, these symptoms can also be associated with other conditions, making them less specific for DVT.
Choice B rationale
Nausea is not typically a symptom of deep vein thrombosis (DVT). The most common symptoms of DVT include swelling of the foot, ankle, or leg, usually on one side, cramping of the affected leg, severe leg pain, and skin on the affected area that is warmer than the skin on surrounding areas.
Choice C rationale
A cool-to-touch extremity is not typically a symptom of deep vein thrombosis (DVT). In fact, the skin over the affected area is often warmer than the skin on surrounding areas. Therefore, a cool-to-touch extremity would not typically be expected in a client with suspected DVT.
Choice D rationale
Calf tenderness when massaged is a common clinical finding in clients with deep vein thrombosis (DVT)2. DVT often causes pain and swelling in the affected leg, and this pain can be particularly noticeable or worsen when the calf is massaged or the client is standing or walking. Therefore, calf tenderness when massaged would be a clinical finding that a nurse should anticipate in a client being admitted with a suspected DVT.
Correct Answer is ["90"]
Explanation
The correct answer is less than 90 beats per minute.
Step 1 is to understand the guidelines for administering digoxin to infants. According to the American Academy of Pediatrics, the nurse should withhold the dose if the infant’s apical heart rate is less than 90 beats per minute.
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