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.

Answer and Explanation

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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Correct Answer is A

Explanation

A. Hyporeflexia is a significant adverse effect of magnesium sulfate therapy and can indicate magnesium toxicity. It is essential for the nurse to monitor deep tendon reflexes as part of the assessment when a client is receiving this medication. A decrease in reflexes may warrant immediate intervention and reporting to the provider.
B. Tachypnea is not a common adverse effect of magnesium sulfate; however, if it occurs, it may indicate respiratory distress, which should be assessed further.
C. Polyuria is not a typical adverse effect of magnesium sulfate. In fact, magnesium can lead to decreased urine output in some cases, especially with toxicity.
D. Agitation is also not a typical adverse effect of magnesium sulfate. Clients receiving magnesium sulfate may exhibit sedation rather than agitation.

A. "You will not be able to eat or drink anything for 8 hours prior to the test." B. "You will press the provided button when you feel the baby moving during the test." C. "You will receive medication through an IV line to stimulate contractions." D. "You will be required to lie flat on your back for the duration of the test."

Correct Answer is B

Explanation

A. There is no fasting requirement for a nonstress test.
B. The client will press a button whenever they feel the baby move during the test to help correlate fetal movement with changes in the fetal heart rate.
C. A nonstress test is not meant to stimulate contractions. It monitors the fetal heart rate in response to the baby's movements.
D. While the client will be monitored, they are not required to lie flat on their back for the entire duration of the test. They may be in a semi-reclining or comfortable position.

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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?

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Naxlex Comprehensive Predictor Exams

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