A nurse is assessing a newborn who is 48 hours old and has a maternal history of methadone use during pregnancy. Which of the following manifestations should the nurse identify as an indication of neonatal abstinence syndrome?
Hyporeactivity.
Excessive high-pitched cry.
Acrocyanosis.
Respiratory rate of 50/min.
The Correct Answer is B
Choice A rationale:
Hyporeactivity is not typically associated with neonatal abstinence syndrome (NAS) NAS is characterized by increased irritability and signs of withdrawal, which are opposite to a hypo- reactive state.
Choice B rationale:
An excessive high-pitched cry is a hallmark sign of neonatal abstinence syndrome. Babies exposed to drugs like methadone during pregnancy can experience withdrawal symptoms, including a distinct high-pitched cry.
Choice C rationale:
Acrocyanosis, a bluish discoloration of the extremities, is a common finding in newborns and is not specific to NAS. It is caused by immature peripheral circulation and usually resolves on its own.
Choice D rationale:
A respiratory rate of 50/min is within the normal range for a newborn and is not a sign of neonatal abstinence syndrome. NAS symptoms are related to drug withdrawal and not respiratory issues.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Continuous abdominal pain and vaginal bleeding in a client with a history of cocaine use are indicative of abruptio placentae. Abruptio placentae is a medical emergency where the placenta detaches from the uterine wall before delivery, leading to severe bleeding and abdominal pain. Immediate medical intervention is necessary to prevent complications for both the mother and the baby.
Choice B rationale:
Hydatidiform mole is a gestational trophoblastic disease that occurs due to an abnormal pregnancy. It is not associated with continuous abdominal pain and vaginal bleeding. Instead, clients with this condition often present with vaginal bleeding and a grape-like cluster of cysts in the uterus.
Choice C rationale:
Preterm labor involves regular uterine contractions and cervical changes before 37 weeks of gestation. While preterm labor can cause abdominal discomfort, it is not usually described as continuous abdominal pain. Vaginal bleeding is not a typical symptom of preterm labor.
Choice D rationale:
Placenta previa is a condition where the placenta covers the opening of the cervix. It can cause painless vaginal bleeding, but it is not usually associated with continuous abdominal pain. Clients with placenta previa often experience sudden, painless bleeding later in pregnancy.
Correct Answer is ["C","D","E"]
Explanation
The correct answers are C, D, E.
Choice A reason:
Performing a vaginal exam is contraindicated in placenta previa because it can disrupt the placenta and cause significant bleeding.
Choice B reason:
Monitoring fetal heart rate with an internal fetal monitor is not recommended as it involves a vaginal exam, which poses a risk of bleeding in placenta previa cases.
Choice C reason:
Frequently assessing maternal heart rate is important to detect any changes that could indicate maternal hemorrhage or other complications.
Choice D reason:
Initiating bed rest with bathroom privileges is advised to minimize the risk of bleeding and to ensure the safety of both the mother and the fetus.
Choice E reason:
Having oxygen equipment available is essential to manage potential fetal distress, which can occur with placenta previa.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today