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
Explanation
Choice A rationale:
The client's statement, "I will check the identification badge of anyone who removes my baby from our room,” indicates an understanding of newborn safety. This statement shows the client's awareness of the importance of verifying the identity of anyone handling their baby before allowing them to be taken out of the room. Checking identification badges helps ensure that only authorized personnel, such as nurses or hospital staff, are allowed to handle the newborn, reducing the risk of unauthorized individuals taking the baby.
Choice B rationale:
This statement is incorrect and does not demonstrate an understanding of newborn safety. Including a photo of the baby along with public birth announcements to social media can compromise the baby's security and privacy. It may expose sensitive information about the baby's location and identity, making the baby vulnerable to potential risks.
Choice C rationale:
This statement is incorrect as it poses a safety risk to the newborn. Allowing the baby to sleep on the bed when the client is in the shower increases the risk of falls or suffocation. The baby should always be placed in a safe sleep environment, such as a crib or bassinet, to minimize the risk of accidents.
Choice D rationale:
This statement is incorrect and does not reflect an understanding of newborn safety. Nurses should not carry the baby in their arms to the nursery. Instead, they should use a crib or an infant carrier to transport the baby safely.
Correct Answer is A
Explanation
The correct answer is A. Apply an ice pack to the affected area. Ice packs are recommended during the first 24 hours after birth to decrease swelling and help with pain.
Choice A reason: Applying an ice pack to the episiotomy site helps reduce swelling and provides pain relief. This is the standard care within the first 24 hours postpartum.
Choice B reason: A warm sitz bath is generally recommended after the first 24 hours following birth. It is not the best immediate action for unrelieved pain shortly after delivery.
Choice C reason: While maintaining cleanliness with a squeeze bottle of antiseptic solution is important for preventing infection, it does not provide the immediate pain relief needed for unrelieved episiotomy pain.
Choice D reason: Heat application, such as placing a hot pack, is not advised within the first 24 hours postpartum because it can increase the risk of swelling and bleeding.
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