A nurse is assessing a newborn of a client who reported methadone use during pregnancy. What manifestations should the nurse expect the newborn to exhibit?
Absent Moro reflex
Weak cry
Poor feeding
Respiratory rate of 30/min
The Correct Answer is C
Correct answer: C. Poor feeding
Newborns exposed to methadone in utero are at risk for neonatal abstinence syndrome (NAS), which can manifest with:
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Poor feeding due to uncoordinated suck and swallow reflexes, irritability, and gastrointestinal symptoms.
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High-pitched cry, not weak—so option B is incorrect.
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Exaggerated Moro reflex, not absent—so option A is incorrect.
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Tachypnea (rapid breathing), often >60/min—so a respiratory rate of 30/min is abnormally low and not expected in this context, making option D incorrect.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C"}
Explanation
Hyperemesis gravidarum is a condition characterized by severe nausea, vomiting, weight loss, and dehydration during pregnancy. The client's laboratory results show signs consistent with dehydration and electrolyte imbalances, such as a low potassium level (3.3 mEq/L) and an elevated blood urea nitrogen (BUN) level (28 mg/dL).
Additionally, the presence of ketones in the urine (not explicitly mentioned in the provided laboratory results but commonly associated with hyperemesis gravidarum) indicates that the body is breaking down fat for energy due to inadequate oral intake and dehydration.
These findings suggest that the client is experiencing significant fluid and electrolyte disturbances, which are commonly seen in hyperemesis gravidarum. Therefore, the client is at risk of developing hyperemesis gravidarum based on the laboratory results indicating dehydration and electrolyte imbalances.
Correct Answer is A
Explanation
Choice A rationale
Puncturing the lateral side of the heel is the correct procedure when performing a heel stick on a newborn. This area is less likely to come into contact with hard surfaces that could cause injury to the puncture site.
Choice B rationale
A 21-gauge needle is too large for a heel stick procedure on a newborn. A smaller gauge needle or a lancet is typically used to ensure the puncture is as small and painless as possible.
Choice C rationale
Applying an alcohol pad to the site after the procedure is not recommended. Alcohol can cause skin irritation and dryness. Instead, a sterile gauze or bandage is usually applied to stop any bleeding from the puncture site.
Choice D rationale
Placing a cold cloth at the site for 15 minutes before the procedure is not recommended. Cold can cause vasoconstriction, which would make it more difficult to obtain a blood sample.
Instead, warming the heel prior to the stick can help to increase blood flow to the area.
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