A nurse is caring for a newborn in the maternity unit
A nurse is assisting in the care of a newborn. Click to highlight the findings that require follow-up. To deselect a finding, click on the finding again.
General: active with strong cry. HEENT: mucous membranes moist. Respiratory: respirations are shallow and irregular. Cardiovascular: S1, S2, no murmur. Musculoskeletal: moves all extremities well and flexed posture. General: active with high-pitched cry. HEENT: mucous membranes moist. Respiratory: respirations are shallow and irregular. Cardiovascular: S1, S2, no murmur. Musculoskeletal: increased muscle tone with tremors noted upon stimulation. Reflexes: positive Babinski, exaggerated Moro, palmar present.
Active with strong cry
Respirations are shallow and irregular
High-pitched cry
Increased muscle tone with tremors noted upon stimulation
Exaggerated Moro reflex
Mucous membranes moist
Correct Answer : B,C,D,E
Choice A rationale: A strong cry in a newborn is a reassuring sign of intact respiratory effort, neurologic function, and overall vitality. It reflects adequate lung expansion, vocal cord function, and central nervous system integrity. In neonatal abstinence syndrome (NAS), a strong cry alone does not indicate distress unless it is high-pitched or persistent. Therefore, this finding does not require follow-up and is consistent with normal neonatal behavior.
Choice B rationale: Shallow and irregular respirations may reflect autonomic instability associated with NAS. Opioid withdrawal affects the brainstem centers regulating respiratory rhythm, leading to inconsistent breathing patterns. This can increase the risk of apnea, desaturation, or feeding difficulties. Normal neonatal respiratory rate ranges from 30 to 60 breaths per minute with periodic breathing, but shallow and irregular patterns in the context of opioid exposure warrant close monitoring and follow-up.
Choice C rationale: A high-pitched cry is a hallmark sign of NAS and indicates central nervous system irritability. It results from increased excitatory neurotransmission and altered pain perception due to opioid withdrawal. This type of cry is often persistent, difficult to console, and reflects heightened neurologic sensitivity. It is distinct from a normal strong cry and requires follow-up to assess severity, initiate scoring protocols, and determine need for pharmacologic or supportive interventions.
Choice D rationale: Increased muscle tone with tremors upon stimulation is a classic manifestation of NAS. Opioid withdrawal disrupts neuromuscular regulation, leading to hypertonia and exaggerated motor responses. Tremors may be spontaneous or stimulus-induced and reflect heightened sympathetic activity. These findings require follow-up to assess withdrawal severity using standardized scoring tools such as the Finnegan scale and to guide management strategies including swaddling, minimizing stimuli, and possible medication.
Choice E rationale: An exaggerated Moro reflex is a sign of central nervous system hyperexcitability, commonly seen in NAS. The Moro reflex is a normal primitive reflex, but when intensified, it reflects neurologic irritability due to withdrawal. This heightened response may interfere with sleep and feeding and contributes to overall distress. Follow-up is needed to monitor progression, evaluate for other neurologic signs, and determine the need for therapeutic interventions.
Choice F rationale: Moist mucous membranes indicate adequate hydration and perfusion. This finding reflects normal fluid balance and is not associated with NAS pathology. It confirms that feeding is sufficient and that there are no signs of dehydration or systemic compromise. Therefore, this finding does not require follow-up and supports stable clinical status in this domain.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
While the date of birth is essential information, asking a parent to state it only provides a detail from the medical record, which does not serve as a primary security confirmation of the newborn's identity for safe transport. The primary identification security relies on matching identifiers between the infant and the parent/guardian at the bedside.
Choice B rationale
The newborn's name is recorded in the medical record after birth, but verbal verification of the name alone is not a fail-safe security measure. Identification protocols require objective data comparison, such as unique numbers on corresponding identification bands, to prevent accidental mismatches and potential abduction.
Choice C rationale
The newborn's footprint sheet is typically used as a permanent record for identification purposes but is not the standard, immediate bedside method for confirming identity before transport. The process requires a direct comparison of unique numerical identifiers on the physical bands worn by the client and the newborn.
Choice D rationale
The most secure method is comparing the unique identification numbers (or codes) on the newborn's band with the band worn by the parent/guardian. This dual-band system, verified by the nurse and the parent, ensures positive identification and is a critical safety protocol to prevent misidentification and potential infant abductions.
Correct Answer is B
Explanation
Choice A rationale
A BP of 105/62 mm Hg is within the expected normal range for a postpartum adolescent client. A typical normotensive range is 90-140 mm Hg systolic and 60-90 mm Hg diastolic. Opioids like morphine can cause mild hypotension, but this reading doesn't indicate an immediate, life-threatening crisis.
Choice B rationale
A respiratory rate of 11/min is the priority because it signifies respiratory depression, a life-threatening, dose-related adverse effect of opioid analgesics like morphine. The normal respiratory rate for an adolescent is 12-20 breaths/min. Rates ≤ 12/min require immediate intervention, including potential administration of an opioid antagonist like naloxone.
Choice C rationale
Urinary retention is a common side effect of opioid administration due to increased bladder sphincter tone and reduced detrusor muscle contractility. While uncomfortable and potentially leading to urinary tract infection or bladder damage, it is less acute and life-threatening than respiratory depression.
Choice D rationale
Blurred vision can be an uncommon side effect of morphine, possibly due to miosis (pupil constriction) or minor changes in intraocular pressure. This finding requires further assessment but is a non-life-threatening adverse effect and does not pose the immediate threat of respiratory depression.
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