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

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.

A. Instruct the client to wash their hands prior to breastfeeding. B. Teach the client about proper latching-on techniques. C. Encourage the client to alternate breastfeeding with formula feeding. D. Instruct the client to avoid using a breast pump. E. Encourage the client to allow their nipples to air dry after feedings.

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.

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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 caring for a client who reports unrelieved episiotomy pain 8 hr following a vaginal birth. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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

Explanation

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