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.

Answer and Explanation

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.

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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.

A. BUN 35 mg/dL. B. Hgb 15 mg/dL. C. Bilirubin 0.6 mg/dL. D. Hct 37%.

Correct Answer is A

Explanation

Choice A rationale:

The nurse should report a blood urea nitrogen (BUN) level of 35 mg/dL to the provider. BUN measures the amount of nitrogen in the blood and is used to assess kidney function. An elevated BUN can indicate impaired renal function, which is a concern in preeclampsia, as it may signify reduced blood flow to the kidneys.

Choice B rationale:

Hemoglobin (Hgb) level of 15 mg/dL is within the normal range for pregnancy (normal range: 11-15 g/dL), so there is no need to report it to the provider.

Choice C rationale:

Bilirubin level of 0.6 mg/dL is within the normal range (normal range: 0.2-1.3 mg/dL), so there is no need to report it to the provider.

Choice D rationale:

Hematocrit (Hct) level of 37% is within the normal range for pregnancy (normal range: 33- 45%), so there is no need to report it to the provider.

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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?

Nursing Test Bank

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