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. Notify the client's provider. B. Document the findings and continue to monitor the client. C. Encourage the client to empty her bladder. D. Increase the frequency of fundal massage.

Correct Answer is B

Explanation

A. Notify the client's provider:
There is no indication that the bleeding is excessive or abnormal at this time. Since the fundus is firm and midline, and the clots are small, this finding is considered typical within the first few hours postpartum. Immediate provider notification is not warranted unless bleeding increases or becomes heavy.

B. Document the findings and continue to monitor the client:
A large amount of lochia rubra with small clots is expected during the early postpartum period, especially within the first 1–2 hours. A firm, midline fundus indicates good uterine tone, minimizing concern for uterine atony. Documentation and ongoing monitoring are appropriate to watch for signs of increased bleeding or changes in the uterus.

C. Encourage the client to empty her bladder:
While a full bladder can cause uterine displacement and contribute to bleeding, the fundus is noted to be midline and at the umbilicus, indicating that the bladder is likely not distended. Encouraging voiding is generally good practice, but it is not indicated by this assessment.

D. Increase the frequency of fundal massage:
Excessive fundal massage when the uterus is already firm and contracted can lead to uterine fatigue or irritation. Fundal massage is indicated when the uterus is boggy or not well-contracted, which is not the case here.

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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 is caring for a client who is 1 hr postpartum and observes a large amount of lochia rubra and several small clots on the client's perineal pad. The fundus is midline and firm at the umbilicus. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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