Nursing care of the infant with neonatal abstinence syndrome should include:
Spending extra time holding and rocking the infant.
Feeding the infant on a 2-hour schedule.
Positioning the infant's crib in a quiet corner of the nursery.
Placing stuffed animals and mobiles in the crib to provide visual stimulation.
The Correct Answer is A
Choice A) Spending extra time holding and rocking the infant is correct because this is an effective and recommended nursing care for an infant with neonatal abstinence syndrome. Neonatal abstinence syndrome (NAS) is a condition that occurs when an infant is exposed to drugs such as opioids, cocaine, or alcohol in utero and goes through withdrawal after birth. NAS can cause various physical and behavioral problems in the infant, such as irritability, poor feeding, vomiting, diarrhea, sweating, fever, or seizures. Holding and rocking the infant can provide comfort, warmth, and security to the infant, as well as reduce stress and pain. It can also promote bonding and attachment between the infant and the caregiver. Therefore, this nursing care should be included in the care plan for an infant with NAS.
Choice B) Feeding the infant on a 2-hour schedule is incorrect because this is not a helpful or appropriate nursing care for an infant with neonatal abstinence syndrome. Feeding is an important aspect of caring for any infant, as it provides nutrients and calories that support growth and development. However, feeding an infant with NAS on a 2- hour schedule may not be suitable or feasible, as NAS can affect the infant's feeding ability and tolerance. An infant with NAS may have difficulty sucking, swallowing, or coordinating breathing during feeding. They may also have frequent vomiting, diarrhea, or dehydration that can interfere with feeding. Therefore, feeding an infant with NAS should be done according to their cues and needs, rather than a fixed schedule. The infant should be offered small, frequent feedings of breast milk or formula, depending on the mother's preference and availability. The infant should also be burped often and held upright after feeding to prevent aspiration or reflux.
Choice C) Positioning the infant's crib in a quiet corner of the nursery is incorrect because this is not a sufficient or optimal nursing care for an infant with neonatal abstinence syndrome. Positioning is an important aspect of caring for any infant, as it affects their comfort, safety, and development. However, positioning an infant with NAS in a quiet corner of the nursery may not be enough or beneficial, as NAS can make the infant more sensitive and responsive to environmental stimuli. An infant with NAS may be easily disturbed or overstimulated by noise, light, or movement in the nursery. They may also feel isolated or neglected if they are placed away from other infants or caregivers.
Therefore, positioning an infant with NAS should be done in a way that minimizes stimulation and maximizes interaction. The crib should be placed in a dimly lit, low noise area of the nursery, but close enough to allow frequent monitoring and contact by the nurse. The crib should also be padded with soft blankets or pillows to prevent injury from excessive movements or seizures.
Choice D) Placing stuffed animals and mobiles in the crib to provide visual stimulation is incorrect because this is not a safe or suitable nursing care for an infant with neonatal abstinence syndrome. Stimulation is an important aspect of caring for any infant, as it enhances their learning and development. However, stimulating an infant with NAS with stuffed animals and mobiles may not be appropriate or advisable, as NAS can make the infant more irritable and restless. An infant with NAS may not enjoy or tolerate visual stimulation from toys or objects in their crib. They may also become agitated or overexcited by them, which can worsen their symptoms or cause complications. Moreover, placing stuffed animals and mobiles in the crib can pose a risk of suffocation, strangulation, or injury for the infant. Therefore, stimulating an infant with NAS should be done in a way that is gentle and gradual. The nurse should use soothing techniques such as talking softly, singing lullabies, or massaging the infant's skin to calm them down. The nurse should also use simple toys such as rattles or balls to engage them in play when they are alert and interested.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice a) Urine output of 200 mL for the past 8 hours is incorrect because this is a normal finding for a postpartum woman. The average urine output for a healthy adult is about 800 to 2000 mL per day, which means about 100 to 250 mL per hour. Therefore, a urine output of 200 mL for the past 8 hours is within the normal range and does not indicate any complications.
Choice b) Weight decrease of 2 pounds since delivery is incorrect because this is also a normal finding for a postpartum woman. The weight loss is due to the expulsion of the placenta, amniotic fluid, and blood during delivery. A postpartum woman can expect to lose about 10 to 12 pounds immediately after giving birth, and another 5 pounds in the following weeks due to fluid loss. Therefore, a weight decrease of 2 pounds since delivery is not a cause for concern and does not need to be reported to the obstetrician.
Choice c) Pulse rate of 65 beats per minute is incorrect because this is also a normal finding for a postpartum woman. The normal resting pulse rate for an adult ranges from 60 to 100 beats per minute, and it may decrease slightly after delivery due to blood loss and reduced cardiac output. Therefore, a pulse rate of 65 beats per minute is not indicative of any problems and does not require any intervention.
Choice d) Drop in hematocrit of 6% since admission is correct because this is an abnormal finding for a postpartum woman and suggests that she has developed anemia due to excessive blood loss. Hematocrit is the percentage of red blood cells in the blood, and it reflects the oxygen-carrying capacity of the blood. The normal hematocrit range for an adult female is 37% to 47%, and it may decrease slightly after delivery due to hemodilution. However, a drop in hematocrit of more than 10% from the baseline or below 30% indicates severe anemia and requires immediate treatment. Therefore, a drop in hematocrit of 6% since admission is a significant change that should be reported to the obstetrician as soon as possible.
Correct Answer is B
Explanation
Choice A) Increased urinary output: This is not a sign of sepsis in newborns. In fact, sepsis can cause reduced urinary output due to poor blood flow to the kidneys and dehydration.
Choice B) Hypothermia: This is a sign of sepsis in newborns. Sepsis can cause changes in temperature, often fever, but sometimes low temperature. Hypothermia can indicate a severe infection that affects the body's ability to regulate its temperature.
Choice C) Wakefulness: This is not a sign of sepsis in newborns. Sepsis can cause reduced activity and lethargy due to inflammation and organ dysfunction.
Choice D) Interest in feeding: This is not a sign of sepsis in newborns. Sepsis can cause reduced sucking and difficulty feeding due to poor appetite, nausea, vomiting, and abdominal distension.
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