A nurse is assessing a newborn who has neonatal abstinence syndrome. Which of the following findings should the nurse expect?
Excessive crying
Decreased muscle tone
Absent Moro reflex
Diminished deep tendon reflexes
The Correct Answer is A
A.
Rationale:
A. Excessive crying:
Correct answer. Neonatal abstinence syndrome (NAS) often presents with irritability, inconsolable crying, and difficulty soothing.
B. Decreased muscle tone: NAS can cause hypertonia or increased muscle tone rather than decreased muscle tone.
C. Absent Moro reflex: NAS may cause hyperactive Moro reflex rather than absent.
D. Diminished deep tendon reflexes: NAS can cause hyperactive deep tendon reflexes rather than diminished.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. A WBC count of 11,000/mm3 is slightly elevated but may be within normal limits, as the normal range for WBC count can vary slightly depending on the laboratory. It is not typically concerning during pregnancy.
B. A hematocrit of 37% is within the normal range for pregnancy (37% to 47%) and does not require immediate reporting to the provider.
C. A fasting blood glucose level of 180 mg/dL is significantly elevated and indicates hyperglycemia, which may be indicative of gestational diabetes mellitus or pre-existing diabetes. This finding should be reported to the provider for further evaluation and management.
D. A creatinine level of 0.9 mg/dL is within the normal range (0.5 to 1 mg/dL) and does not require immediate reporting to the provider.
Correct Answer is D
Explanation
Rationale:
A. A temperature of 37.4°C (99.3°F) may be within the normal range, but it can also indicate a fever, which is common with endometritis.
B. A WBC count of 9,000/mm3 is within the normal range, but it may be elevated in response to infection such as endometritis.
C. Scant lochia is not typically associated with endometritis; instead, clients with endometritis may have increased or foul-smelling lochia.
D. Uterine tenderness is a common finding in clients with endometritis, as the infection causes inflammation and discomfort in the uterine lining.
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