Which nursing interventions are appropriate while caring for a newborn whose mother was addicted to heroin during the pregnancy? (Select All that Apply.)

Offer the newborn a pacifier

Observe the newborn in a well-lit nursery

Maintain low stimulation environment

Administer oral glucose for comfort

Swaddle newborn tightly

Feed the infant half strength formula

Answer and Explanation

Correct Answer : A,C,E

A. Offer the newborn a pacifier. This can help soothe the newborn and provide comfort, as infants exposed to opioids in utero often exhibit increased need for sucking.
B. Observe the newborn in a well-lit nursery. This is not appropriate as bright lights can overstimulate and distress the newborn.
C. Maintain a low stimulation environment. This helps reduce stress and irritability in newborns undergoing withdrawal, who can be hypersensitive to stimuli.
D. Administer oral glucose for comfort. Glucose is not typically used for comfort in NAS management; comforting measures like swaddling and pacifiers are preferred.
E. Swaddle the newborn tightly. Tight swaddling can provide a sense of security and help manage symptoms of neonatal abstinence syndrome (NAS) by reducing irritability and promoting sleep.
F. Feed the infant half-strength formula. Infants with NAS usually require regular, full-strength formula to meet nutritional needs unless otherwise indicated by specific feeding issues.

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Correct Answer is D

Explanation

A. Reprimand the client about the potential damage that has occurred due to overexercising her body: Reprimanding is likely to increase feelings of guilt and shame, which can exacerbate the disorder. A supportive and empathetic approach is more beneficial.
B. Praise the client for looking at herself in a mirror: This could reinforce a negative preoccupation with body image, which is a significant aspect of anorexia nervosa. Encouraging healthy coping mechanisms is more appropriate.
C. Restrict the client from being weighed: While it is important to manage weight monitoring carefully, outright restriction without addressing the underlying issues can increase anxiety and resistance to treatment.
D. Ask the client to agree to talk to a nurse whenever she feels the urge to exercise: This helps the client develop healthier coping strategies and provides support in managing the urge to overexercise, promoting therapeutic engagement.

Correct Answer is []

Explanation

Complication: Otitis Media

Anatomical Changes:

Small external ear structure: Infants born with a cleft palate often have smaller external ear structures, which can affect the drainage of fluids and increase the risk of infections.
Horizontal eustachian tubes: Eustachian tubes in individuals with cleft palate are typically more horizontal than normal, impairing the drainage of fluid from the middle ear.
Large tongue: A large tongue may obstruct the upper airway and interfere with normal swallowing and speaking functions.

Complication: Otitis Media

Due to the anatomical changes associated with cleft palate, such as horizontal eustachian tubes and impaired drainage, individuals are prone to recurrent middle ear infections (otitis media). These infections can lead to fluid accumulation behind the eardrum, which can further impair hearing and potentially lead to more serious complications if untreated.

Priority Interventions:

Ear drops (for otitis media): Ear drops containing antibiotics may be prescribed to treat bacterial infections in the middle ear, which are common in individuals with cleft palate.
- Rationale: Ear drops help to directly treat the infection in the ear canal and middle ear, reducing inflammation and preventing complications such as hearing loss or spread of infection.
Corticosteroids (for inflammation): Corticosteroids may be used to reduce inflammation in the ear canal and middle ear, particularly in cases of severe otitis media.
- Rationale: Corticosteroids help to decrease swelling and inflammation, which can improve symptoms and aid in the healing process of the ear.

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Which nursing interventions are appropriate while caring for a newborn whose mother was addicted to heroin during the pregnancy? (Select All that Apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client diagnosed with anorexia nervosa and over exercises to avoid gaining weight. Which of the following should be the appropriate action by the nurse?

Correct Answer is D

Explanation

Identify a complication resulting from a cleft palate, the anatomical changes that lead to the complication, and the priority interventions for care.

Correct Answer is []

Explanation

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