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.

Answer and Explanation

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.

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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.

A. Keep the newborn dressed while receiving phototherapy. B. Apply lotion to the skin twice daily. C. Maintain an eye mask over the newborn's eyes. D. Maintain the phototherapy during blood draws.

Correct Answer is C

Explanation

Choice A rationale:

Keeping the newborn dressed while receiving phototherapy is not recommended because the baby's skin needs to be exposed to the light to effectively treat hyperbilirubinemia. Direct exposure to light helps break down the excess bilirubin in the baby's blood, leading to its excretion.

Choice B rationale:

Applying lotion to the skin twice daily is contraindicated during phototherapy. Lotions and creams can block the light from reaching the skin and hinder the therapeutic effects of the phototherapy. The baby's skin should remain exposed to the light for optimal treatment.

Choice C rationale:

Maintaining an eye mask over the newborn's eyes is essential during phototherapy. The eyes are sensitive to light, and prolonged exposure to the phototherapy light can lead to eye damage. Using an eye mask protects the baby's eyes while allowing the rest of the body to receive the necessary light treatment.

Choice D rationale:

Maintaining the phototherapy during blood draws is crucial to ensure continuous treatment of hyperbilirubinemia. Interrupting the phototherapy during blood draws might result in the rebound of bilirubin levels, which can be harmful to the baby.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who is 2 weeks postpartum and has mastitis. Which of the following interventions should the nurse include? (Select all that apply.)

Correct Answer is ["A","B","E"]

Explanation

A nurse is caring for a newborn with hyperbilirubinemia. Which of the following interventions should be taken during phototherapy?

Correct Answer is C

Explanation

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