A nurse is assisting in the care of a newborn who is 72 hours old and is receiving treatment for neonatal abstinence syndrome.
Which of the following data collection findings should the nurse identify as requiring immediate follow-up? (Select all that apply.).
Blood pressure.
Gastrointestinal disturbances.
Skin color.
NAS score.
Temperature.
Oxygen saturation.
Central nervous system disturbances.
Respiratory rate
Correct Answer : B,D,F,H
Choice A:
Blood pressure is not a priority finding for a newborn with neonatal abstinence syndrome (NAS). Blood pressure may be slightly elevated or normal in NAS, but it is not a sign of severe withdrawal or a risk for complications. •
Choice B:
Gastrointestinal disturbances are common and serious symptoms of NAS. They include poor feeding, vomiting, diarrhea, dehydration and poor weight gain. These can lead to electrolyte imbalance, malnutrition and failure to thrive. This choice requires immediate follow-up. •
Choice C:
Skin color is not a priority finding for a newborn with NAS. Skin color may be normal or slightly pale in NAS, but it is not a sign of severe withdrawal or risk for complications. •
Choice D:
NAS score is a priority finding for a newborn with NAS. NAS score is a tool used to assess the severity of withdrawal symptoms and the need for pharmacological treatment. A high NAS score indicates that the newborn needs medication to manage the withdrawal and prevent complications such as seizures. This choice requires immediate follow-up. •
Choice E:
Temperature is not a priority finding for a newborn with NAS. The temperature may be slightly elevated or normal in NAS, but it is not a sign of severe withdrawal or risk for complications. •
Choice F:
Oxygen saturation is a priority finding for a newborn with NAS. Oxygen saturation measures the amount of oxygen in the blood. Low oxygen saturation can indicate respiratory distress, which is a common and serious symptom of NAS. Respiratory distress can lead to hypoxia, acidosis, and brain damage. This choice requires immediate follow-up. •
Choice G:
Central nervous system disturbances are common and serious symptoms of NAS. They include tremors, irritability, excessive crying, hyperactivity, increased muscle tone, seizures, and sleep problems. These can indicate severe withdrawal and risk for neurological damage. This choice requires immediate follow-up.
Choice H:
Respiratory rate is a priority finding for a newborn with NAS. The respiratory rate measures the number of breaths per minute. A high respiratory rate can indicate respiratory distress, which is a common and serious symptom of NAS. Respiratory distress can lead to hypoxia, acidosis, and brain damage. This choice requires immediate follow-up.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","E"]
Explanation
Choice A:
Tremors. This is a sign of hypoglycemia in a newborn because low blood sugar can cause shakiness or jitteriness in the muscles. •
Choice B:
Lethargy. This is a sign of hypoglycemia in a newborn because low blood sugar can cause low energy, poor feeding, or lack of interest in eating.
Choice C:
Hunger. This is not a sign of hypoglycemia in a newborn because low blood sugar can actually reduce the appetite or cause feeding difficulties.
Choice D:
Jaundice. This is not a sign of hypoglycemia in a newborn because jaundice is caused by high levels of bilirubin in the blood, not low levels of glucose.
Choice E:
Weak cry. This is a sign of hypoglycemia in a newborn because low blood sugar can affect the vocal cords and the respiratory system, causing a weak or high-pitched cry.
Correct Answer is B
Explanation
Choice A reason:
Diminished deep-tendon reflexes are a sign of magnesium toxicity, not safety. Magnesium sulfate is a central nervous system depressant that can cause muscle weakness, respiratory depression, and cardiac arrest if given in excess. The nurse should monitor the client's deep-tendon reflexes and stop the infusion if they are absent or reduced.
Choice B reason:
A respiratory rate of 16/min is a normal finding and indicates that the client is not experiencing respiratory depression from magnesium sulfate. The nurse should monitor the client's respiratory rate and stop the infusion if it falls below 12/min.
Choice C reason:
A heart rate of 60/min is a normal finding and indicates that the client is not experiencing bradycardia from magnesium sulfate. The nurse should monitor the client's heart rate and stop the infusion if it falls below 50/min.
Choice D reason:
Urine output of 50 mL in 4 hr is a sign of oliguria, not safety. Magnesium sulfate can cause renal impairment and fluid retention if given in excess. The nurse should monitor the client's urine output and stop the infusion if it falls below 30 mL/hr.
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