A nurse is assessing a newborn who is 48 hr 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.
The Correct Answer is B
Choice A rationale:
Hyporeactivity, or reduced responsiveness to stimuli, is not typically associated with neonatal abstinence syndrome (NAS) NAS is characterized by increased irritability and not reduced activity.
Choice B rationale:
An excessive high-pitched cry is a common manifestation of neonatal abstinence syndrome. Infants exposed to substances like methadone during pregnancy may experience heightened sensitivity and exhibit a high-pitched cry as a sign of withdrawal.
Choice C rationale:
Acrocyanosis, a bluish discoloration of the hands and feet, is not a specific indicator of neonatal abstinence syndrome. It is a common finding in newborns and often resolves on its own.
Choice D rationale:
A respiratory rate of 50/min is within the normal range for a newborn. It is not an indication of neonatal abstinence syndrome.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is B
Explanation
Assess the fetal heart rate pattern.
Choice B rationale:
When a laboring client's membranes have just ruptured, the nurse's next action should be to assess the fetal heart rate pattern. Rupture of membranes can lead to changes in amniotic fluid, which can affect the fetal environment and potentially cause fetal distress. By assessing the fetal heart rate pattern, the nurse can determine if the baby is tolerating the labor process well or if there are signs of fetal compromise that require further intervention.
Choice A rationale:
While assessing the client's blood pressure (Choice A) is important during labor, it is not the immediate next action when the membranes have ruptured.
Choice C rationale:
Taking the client's temperature (Choice C) is also important, but it is not the priority action when the membranes have ruptured.
Choice D rationale:
Preparing for a c-section (Choice D) is not the initial action unless there are specific indications for an emergency cesarean section. Assessing the fetal heart rate is more critical at this stage.
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