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 B
Explanation
Choice A: This is incorrect because acetylsalicylic acid (ASA), also known as aspirin, is not a cure for preeclampsia, but a preventive measure. ASA may reduce the risk of preeclampsia in some high-risk women by inhibiting platelet aggregation and improving blood flow to the placenta. However, ASA is not recommended for all pregnant women, as it may have adverse effects on the mother and the fetus, such as bleeding, premature closure of the ductus arteriosus, or fetal growth restriction.
Choice B: This is the correct answer because delivery of the fetus is the only definitive treatment for preeclampsia, as it eliminates the source of the placental factors that cause the condition. Preeclampsia is a multisystem disorder characterized by hypertension, proteinuria, and edema that occurs after 20 weeks of gestation. It is caused by abnormal placentation and endothelial dysfunction that lead to vasoconstriction, inflammation, and coagulation.
Delivery of the fetus and the placenta resolves these abnormalities and restores normal maternal physiology.
Choice C: This is incorrect because antihypertensive medications are not a cure for preeclampsia, but a symptomatic management. Antihypertensive medications may lower the blood pressure and reduce the risk of maternal complications, such as stroke, seizure, or organ damage. However, antihypertensive medications do not address the underlying cause of preeclampsia and do not improve fetal outcomes. Moreover, some antihypertensive medications are contraindicated in pregnancy due to their teratogenic effects.
Choice D: This is incorrect because magnesium sulfate is not a cure for preeclampsia, but a prophylaxis for eclampsia. Eclampsia is a severe complication of preeclampsia that involves seizures and coma. Magnesium sulfate is an anticonvulsant that prevents or treats eclamptic seizures by stabilizing neuronal membranes and reducing cerebral edema. However, magnesium sulfate does not lower blood pressure or improve renal function in preeclamptic women. It also has side effects such as nausea, flushing, headache, or respiratory depression.
Correct Answer is D
Explanation
Choice A) Report of absent breast pain is incorrect because this is not a finding that indicates that the medication was effective, but rather a finding that indicates that the client does not have mastitis or engorgement. Mastitis is an infection of the breast tissue that causes pain, swelling, redness, and fever. Engorgement is a condition where the breasts become overfilled with milk, causing pain, hardness, and leakage. Both conditions are common in postpartum women who are breastfeeding, but they are not related to methylergonovine or uterine bleeding. Therefore, this response is irrelevant and inaccurate.
Choice B) Increase in lochia is incorrect because this is not a finding that indicates that the medication was effective, but rather a finding that indicates that the medication was ineffective or that the client has a complication. Lochia is the vaginal discharge that consists of blood, mucus, and tissue from the uterus after childbirth. It usually lasts for about 4 to 6 weeks and gradually decreases in amount and color. Methylergonovine is a medication that helps to control uterine bleeding by improving the tone and contractions of the uterus. An increase in lochia may mean that methylergonovine did not work well or that the client has a problem such as retained placenta, infection, or subinvolution. Therefore, this response is opposite and inaccurate.
Choice C) Increase in blood pressure is incorrect because this is not a finding that indicates that the medication was effective, but rather a finding that indicates that the client has a side effect or a risk factor. Blood pressure is the force of blood against the walls of the arteries. It is measured by two numbers: systolic (the pressure when the heart beats) and diastolic (the pressure when the heart rests). The normal range for blood pressure is 120/80 mm Hg or lower. Methylergonovine is a medication that can cause vasoconstriction, which means narrowing of the blood vessels and increasing of the blood pressure. This can lead to complications such as hypertension, stroke, or heart attack. Therefore, this response is adverse and inaccurate.
Choice D) Fundus firm to palpation is correct because this is a finding that indicates that the medication was effective and that the client has a good outcome. The fundus is the upper part of the uterus that can be felt through the abdomen after childbirth. It should be firm, midline, and at or below the level of the navel. A firm fundus means that the uterus has contracted well and stopped bleeding. Methylergonovine is a medication that helps to achieve this by improving the tone and contractions of the uterus. Therefore, this response is positive and accurate.
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