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.
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Related Questions
Correct Answer is A
Explanation
A. To facilitate bonding between the newborn and parent. This is correct. Antibiotic ophthalmic ointment, typically used to prevent neonatal conjunctivitis, can temporarily blur the newborn's vision. Delaying its application for a short period allows the newborn to maintain eye contact with the parent during the critical bonding period immediately following birth.
B. To allow manifestations of infection to be identified. This is incorrect. The purpose of the antibiotic ointment is to prevent neonatal conjunctivitis caused by gonorrhea or chlamydia, which may not present with immediate symptoms. Delaying its application to observe for signs of infection would not be appropriate.
C. The newborn's weight is not a determining factor for delaying the instillation of antibiotic ophthalmic ointment.
D. The mode of delivery, whether vaginal or cesarean, does not affect the timing of antibiotic ophthalmic ointment instillation.
Correct Answer is B
Explanation
Rationale:
A. A blood pressure of 120/70 mm Hg is within the normal range for a postpartum client and does not require immediate reporting to the provider.
B. Cool clammy skin may indicate hypoperfusion or inadequate blood flow, which could be a sign of hemorrhage or other circulatory issues. This finding should be reported promptly for further evaluation and intervention.
C. Moderate lochia serosa is a normal finding in the early postpartum period and does not typically require immediate reporting.
D. A heart rate of 89/min is within the normal range for a postpartum client and does not require immediate reporting to the provider.
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