A nurse is assessing a term newborn who is 48 hours old.

The mother has a history of opioid use during pregnancy and was prescribed methadone.

Based on the findings 24 hours later, how should the nurse interpret the findings?

Transient strabismus

Mottling

Respiratory rate of 70/min

Loose stools

Regurgitation

Answer and Explanation

The Correct Answer is C

Choice A rationale
Transient strabismus, or temporary misalignment of the eyes, is not typically a symptom observed in newborns exposed to opioids during pregnancy.
Choice B rationale
Mottling, or patchy skin color, is a common physical characteristic in newborns and is not specifically associated with opioid exposure during pregnancy.
Choice C rationale
A respiratory rate of 70/min is significantly higher than the normal range for a newborn, which is typically between 30 and 60 breaths per minute. This could be a sign of neonatal abstinence syndrome (NAS), a group of conditions caused by withdrawal from certain drugs that the newborn was exposed to in the womb.
Choice D rationale
Loose stools are not typically associated with opioid exposure during pregnancy.
Choice E rationale
Regurgitation, or spitting up, is common in newborns and is not specifically associated with opioid exposure during pregnancy.

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Correct Answer is C

Explanation

Choice A rationale
Contractions feeling further apart is not a direct indicator of the effectiveness of the hands-and-knees position in relieving discomfort associated with a fetus in the occipitoposterior position.
Choice B rationale
Feeling relief from pelvic pressure may not directly indicate the effectiveness of the hands-and-knees position in relieving discomfort associated with a fetus in the occipitoposterior position.
Choice C rationale
Improvement in back labor is a direct indicator of the effectiveness of the hands-and-knees position in relieving discomfort associated with a fetus in the occipitoposterior position.
Choice D rationale
Lessening of suprapubic pain may not directly indicate the effectiveness of the hands-and-knees position in relieving discomfort associated with a fetus in the occipitoposterior position.

A. Avoid performing sterile vaginal examinations B. Administer betamethasone IM C. Obtain a specimen for a Kleihauer-Betke test D. Anticipate a prescription for misoprostol

Correct Answer is D

Explanation

Choice A rationale
Avoiding performing sterile vaginal examinations does not directly address the issue of uterine atony and excessive bleeding. While limiting vaginal examinations can reduce the risk of infection, it does not treat uterine atony.
Choice B rationale
Administering betamethasone IM is not the appropriate action. Betamethasone is a steroid medication that is often given to pregnant women who are at risk of preterm birth to help mature the baby’s lungs. It does not treat uterine atony or excessive bleeding.
Choice C rationale
Obtaining a specimen for a Kleihauer-Betke test is not the appropriate action in this situation. The Kleihauer-Betke test is used to detect fetal blood in maternal circulation, which is not relevant in this case.
Choice D rationale
Anticipating a prescription for misoprostol is the correct action. Misoprostol is a medication that can be used to treat uterine atony by causing the uterus to contract, which can help control postpartum bleeding.

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A nurse is assessing a term newborn who is 48 hours old. The mother has a history of opioid use during pregnancy and was prescribed methadone. Based on the findings 24 hours later, how should the nurse interpret the findings?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is in active labor with a fetus in the occipitoposterior position. The nurse assists the client in a hands-and-knee position. Which should the nurse ask to evaluate the effectiveness of this intervention?

Correct Answer is C

Explanation

A nurse is caring for a client who is 1 hour postpartum and has uterine atony. The client is exhibiting a large amount of vaginal bleeding. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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A nurse is assessing a term newborn who is 48 hours old.

The mother has a history of opioid use during pregnancy and was prescribed methadone.

Based on the findings 24 hours later, how should the nurse interpret the findings?