A nurse is assisting with the care of a newborn who has neonatal abstinence syndrome. Which of the following actions should the nurse take first?
Weigh the newborn's wet diaper.
Auscultate the newborn's bowel sounds.
Determine the newborn's respiratory rate.
Swaddle the newborn in blankets.
The Correct Answer is C
A. weighing the newborn's wet diaper, is a routine part of newborn care but is not the first priority in this situation.
B. auscultating the newborn's bowel sounds, is important for assessing gastrointestinal function but is not the first priority when the baby is at risk for respiratory distress.
C. Neonatal abstinence syndrome (NAS) is a condition that occurs in newborns who were exposed to addictive substances in utero. One of the key concerns in NAS is respiratory distress, so determining the newborn's respiratory rate is the first priority.
D. swaddling the newborn in blankets, is a comfort measure but does not address the immediate concern of assessing respiratory status in a baby with suspected NAS.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. applying petroleum jelly to the suppository, is not necessary and may interfere with the medication's absorption.
B. Inserting the suppository along the posterior vaginal wall as far up as one can go.
C. inserting the suppository 5 cm (2 in), is the incorrect technique for administering a vaginal suppository. It should be administered as high up as one comfortably can
D. assisting the client into a prone position, is unnecessary and not related to the administration of the suppository.
Correct Answer is A
Explanation
A. At 12 weeks of gestation, the nurse should expect to find the fetal heart tones in the suprapubic area. This is where the uterus is located at this early stage of pregnancy.
B. This is not the correct location for auscultating fetal heart tones at 12 weeks of gestation. The umbilical area is not the typical location for auscultating fetal heart tones at this stage.
C. This is not the correct location for auscultating fetal heart tones at 12 weeks of gestation. At this stage, the nurse should expect to find fetal heart tones in the suprapubic region.
D. This is not the correct location for auscultating fetal heart tones at 12 weeks of gestation. The liver is typically not involved in auscultating fetal heart tones at this stage.
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