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A nurse is caring for a newborn who is 5 days old.

Exhibits
Which of the following actions should the nurse take? Select all that apply.

Instruct the parent to avoid eye contact with the newborn during feeding.

Weigh the newborn daily.

Plan to administer naloxone.

Instruct the parent to avoid breastfeeding

Maintain a low stimulation environment

Swaddle the newborn with flexed extremities.

Perform Ballard newborn screening each shift.

Answer and Explanation

Correct Answer : B,E,F

A. Instruct the parent to avoid eye contact with the newborn during feeding – This is not recommended. While overstimulation should be minimized, gentle eye contact and bonding are still encouraged during feeding to promote attachment.

B. Weigh the newborn daily – Weight loss and feeding difficulties are common in NAS. Daily weight monitoring is essential to evaluate nutritional status and fluid balance.

C. Plan to administer naloxone – Naloxone is contraindicated in opioid-exposed neonates because it can precipitate acute withdrawal and seizures.

D. Instruct the parent to avoid breastfeeding – Breastfeeding is generally encouraged unless the mother is using illicit substances or is HIV-positive. Methadone is not a contraindication for breastfeeding.

E. Maintain a low stimulation environment – NAS newborns are easily overstimulated. A quiet, dimly lit environment helps reduce symptoms like irritability and tremors.

F. Swaddle the newborn with flexed extremities – Swaddling provides comfort and containment, helping to reduce stress responses in NAS infants.

G. Perform Ballard newborn screening each shift – The Ballard score is used once to assess gestational age and is not repeated every shift.

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Correct Answer is B

Explanation

A. Moderate alcohol intake is not a contraindication to COC use.
B. Breastfeeding in the first 6 weeks postpartum is a contraindication to combined oral contraceptives because estrogen can reduce milk supply and increase the risk of thrombosis.
C. High body weight is not an absolute contraindication, though efficacy may be reduced.
D. Age 25 alone is not a contraindication to COCs.

A. Administer an IV bolus of lactated Ringer's B. Monitor for clonus C. Obtain a prescription for misoprostol D. Restrict daily oral fluid intake.

Correct Answer is B

Explanation

A. IV fluids should be administered cautiously in preeclampsia to avoid fluid overload; an IV bolus is not routinely indicated.
B. Monitoring for clonus is important, as it is a sign of increased neuromuscular irritability and risk of seizure in preeclampsia.
C. Misoprostol is used to manage postpartum bleeding but is not specific to preeclampsia management.
D. Fluid restriction is generally not recommended unless there are signs of fluid overload or other complications.

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A nurse is caring for a newborn who is 5 days old. Exhibits Which of the following actions should the nurse take? Select all that apply.

Nursing Test Bank

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A nurse is caring for a newborn who is 5 days old.

Exhibits
Which of the following actions should the nurse take? Select all that apply.