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.
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Related Questions
Correct Answer is ["A","B","D"]
Explanation
A. Correct. Large for gestational age (LGA. infants may have a higher risk of birth injuries, including ecchymosis (bruising) due to their size.
B. Correct. Encouraging breastfeeding is important for all newborns, including those who are large for gestational age.
C. This action is not specifically related to caring for a newborn who is large for gestational age. Meconium may be collected for other reasons, but it is not a priority in this situation.
D. Correct. LGA infants are at increased risk for hypoglycemia due to maternal gestational diabetes. Monitoring blood glucose levels is important.
E. This action is not typically indicated for newborns who are large for gestational age. It is important to focus on monitoring and providing supportive care unless there arespecific medical indications for a blood transfusion.
Correct Answer is D
Explanation
A. administering misoprostol, may be indicated in postpartum care, but it is not the first priority in this situation. The immediate concern is excessive bleeding, which should be addressed first.
B. increasing maintenance IV fluid, is not the first action to take. While fluid management is important, it is not the priority when the client is experiencing excessive postpartum bleeding.
C. performing perineal hygiene, is important for overall hygiene, but it is not the first action to take when the client is experiencing excessive bleeding. Controlling bleeding takes precedence.
D. performing fundal assessment and massage, is the first priority. This helps assess for uterine atony (failure of the uterus to contract), a common cause of postpartum hemorrhage. Massage can stimulate uterine contractions and help control bleeding.
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