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 D
Explanation
Choice A rationale:
A client who gave birth 1 day ago and needs Rh(D) immune globulin should be seen soon but not necessarily first. Rh(D) immune globulin is administered to Rh-negative mothers with Rh- positive infants to prevent isoimmunization in future pregnancies.
Choice B rationale:
A client who gave birth 3 days ago and reports breast fullness is likely experiencing normal postpartum breast engorgement. This client can be attended to after the client with more urgent symptoms.
Choice C rationale:
A client who gave birth 12 hours ago and reports an increase in urinary output might have diuresis, which is a common postpartum physiological change. Although this requires assessment, it is not as urgent as the client in choice D.
Choice D rationale:
The nurse should see the client who gave birth 8 hours ago and is saturating a perineal pad every hour first because excessive postpartum bleeding could indicate hemorrhage, a potentially life-threatening complication. Immediate assessment and intervention are crucial in this situation.
Correct Answer is B
Explanation
Choice A rationale:
An axillary temperature of 36.5°C (97.7°F) is within the normal range for a newborn. Normal axillary temperature for a newborn is typically between 36.5°C to 37.5°C (97.7°F to 99.5°F).
Choice B rationale:
This is the correct choice. Nasal flaring in a newborn is a concerning sign and may indicate respiratory distress. It suggests that the baby is having difficulty breathing and should be reported to the provider for further evaluation.
Choice C rationale:
A heart rate of 158/min is within the normal range for a newborn. The normal heart rate for a newborn can range from 100 to 160 beats per minute.
Choice D rationale:
Having one void since birth is not a concerning finding for a 10-hour-old newborn. In the early hours of life, the frequency of voids may vary, but the baby should have an increasing number of wet diapers in the following days.
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