For an infant experiencing symptoms of drug withdrawal, which intervention should be included in the plan of care?

Feeding every 4 to 6 hours to allow extra rest between feedings

Administering chloral hydrate for sedation

Playing soft music during feeding

Snugly swaddling the infant and tightly holding the baby

Answer and Explanation

The Correct Answer is D

A. Feeding every 4 to 6 hours to allow extra rest between feedings: Infants experiencing withdrawal often have feeding difficulties and poor weight gain. They require frequent, small feedings (every 2–3 hours), not prolonged intervals, to maintain nutrition and comfort.

B. Administering chloral hydrate for sedation: Sedation with medications like chloral hydrate is not a first-line treatment and is generally avoided unless absolutely necessary. Non-pharmacologic interventions are prioritized in managing neonatal abstinence syndrome.

C. Playing soft music during feeding: While soft music may be soothing, infants in withdrawal are often hypersensitive to stimuli. Even soft sounds can overstimulate them, leading to increased irritability and distress.

D. Snugly swaddling the infant and tightly holding the baby: Swaddling provides containment and comfort, helping reduce tremors and irritability. It minimizes sensory overload and promotes neurologic stability in infants experiencing withdrawal.

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Correct Answer is C

Explanation

A. 22/min: A respiratory rate of 22 breaths per minute is well below the normal range for a newborn. This could indicate respiratory depression or central nervous system suppression, both of which are concerning in a neonate and require immediate evaluation.

B. 110/min:. A respiratory rate of 110/min suggests tachypnea, which may be due to transient tachypnea, respiratory distress, or sepsis and warrants further assessment.

C. 48/min: The normal respiratory rate for a newborn is between 30 to 60 breaths per minute. A rate of 48/min falls comfortably within this expected range, indicating adequate respiratory function. Breathing should also be assessed for regularity, absence of grunting, and use of accessory muscles.

D. 100/min: This respiratory rate is much too high for a newborn and indicates marked tachypnea, which could be associated with respiratory compromise such as hyaline membrane disease, meconium aspiration, or pneumonia. Immediate evaluation would be needed in such cases.

A. Reinforce postpartum and newborn care discharge teaching. B. Assist the family to identify prior use of positive coping skills in family crises. C. Ask the client if she has considered harming her newborn. D. Anticipate a prescription by the provider for an antidepressant.

Correct Answer is C

Explanation

A. Reinforce postpartum and newborn care discharge teaching: While reinforcing teaching about postpartum care is important, the priority action is to assess the client’s emotional and mental well-being, as there are signs of possible depression or more severe emotional distress.

B. Assist the family to identify prior use of positive coping skills in family crises: While assessing coping skills can be beneficial in supporting the client, the immediate concern is the client's mental state and potential risk to herself or her newborn, which requires prompt attention.

C. Ask the client if she has considered harming her newborn: This is the priority action. The client’s report of feeling "down," sad, having no energy, and wanting to cry may indicate postpartum depression or more severe conditions like postpartum psychosis, which could pose a risk to both the client and her newborn. Asking directly about harm to the newborn is crucial for ensuring safety and guiding the next steps for care.

D. Anticipate a prescription by the provider for an antidepressant: While antidepressants may be prescribed for postpartum depression, the priority is to assess the client's safety first and intervene as needed before proceeding with treatment options. The provider will determine the appropriate treatment based on a comprehensive evaluation.

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For an infant experiencing symptoms of drug withdrawal, which intervention should be included in the plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a newborn 1 hr after birth. Which of the following respiratory rates is within the expected reference range for a newborn?

Correct Answer is C

Explanation

A nurse in a clinic is caring for a client who is 3 weeks postpartum following the birth of a healthy newborn. The client reports feeling "down" and sad, having no energy, and wanting to cry. Which of the following is a priority action by the nurse?

Correct Answer is C

Explanation

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