A nurse is assessing a newborn who is 48 hours old and is experiencing opioid withdrawals. Which of the following findings should the nurse expect?
Hypotonicity.
Moderate tremors of the extremities.
Axillary temperature 36.1°C (96.9°F)
Excessive sleeping.
The Correct Answer is B
Choice A rationale:
Hypotonicity, or decreased muscle tone, is not an expected finding in a newborn experiencing opioid withdrawals. Opioid withdrawal symptoms usually involve increased muscle tone and jitteriness.
Choice B rationale:
Moderate tremors of the extremities are an expected finding in a newborn experiencing opioid withdrawals. Neonates born to mothers who used opioids during pregnancy can exhibit tremors, irritability, and other withdrawal symptoms.
Choice C rationale:
An axillary temperature of 36.1°C (96.9°F) is within the normal range for a newborn's body temperature, so it is not directly related to opioid withdrawal and is not the expected finding in this situation.
Choice D rationale:
Excessive sleeping is not an expected finding in a newborn experiencing opioid withdrawals. Opioid withdrawal can lead to increased wakefulness and irritability in newborns.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","E"]
Explanation
Choice A rationale:
Instructing the client to wash their hands before breastfeeding helps prevent the transmission of infection to the breast and the baby.
Choice B rationale:
Teaching the client about proper latching-on techniques ensures effective breastfeeding, reduces the risk of nipple damage, and promotes comfort for both the client and the baby.
Choice C rationale:
Encouraging the client to alternate breastfeeding with formula feeding is not recommended for a client with mastitis. Mastitis is an inflammation of the breast tissue often caused by bacterial infection, and continuing breastfeeding helps to clear the infection and maintain milk supply.
Choice D rationale:
Instructing the client to avoid using a breast pump is not necessary in this situation. Breastfeeding and pumping can continue to help drain the breast adequately, which is essential for resolving mastitis.
Choice E rationale:
Encouraging the client to allow their nipples to air dry after feedings helps promote healing and prevents further irritation to the nipples.
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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