A nurse is caring for a newborn who is 5 days old in the neonatal intensive care unit (NICU).
Exhibits
Which of the following actions should the nurse take? (Select all that apply)
Swaddle the newborn with flexed extremities.
Plan to administer naloxone.
Maintain a low stimulation environment.
Instruct the parent to avoid breastfeeding.
Perform Ballard newborn screening each shift.
Weigh the newborn daily.
Instruct the parent to avoid eye contact with the newborn during feeding.
Correct Answer : A,C,F
Choice A rationale: Swaddling the newborn with flexed extremities can provide a sense of security and help soothe the newborn. This is a common practice in managing neonates with Neonatal Abstinence Syndrome (NAS) as it can help reduce irritability and promote sleep.
Choice B rationale: Naloxone is not typically used in the treatment of NAS. Naloxone is an opioid antagonist and can precipitate withdrawal symptoms in opioid-dependent individuals. In a neonate with NAS due to maternal opioid use, naloxone can cause severe and immediate withdrawal.
Choice C rationale: Maintaining a low stimulation environment is crucial in managing neonates with NAS. These neonates are often hypersensitive to stimuli, and a quiet, dimly lit environment can help reduce irritability and promote sleep.
Choice D rationale: Breastfeeding is usually encouraged in mothers who are stable on their opioid replacement therapy, are not using illicit drugs, and have no other contraindications for breastfeeding. The benefits of breastfeeding include the passage of maternal antibodies and the promotion of mother-infant bonding.
Choice E rationale: The Ballard newborn screening is a tool used to estimate gestational age using physical and neuromuscular characteristics. It is typically performed shortly after birth and may not need to be performed each shift in a neonate with NAS.
Choice F rationale: Weighing the newborn daily is important in the management of NAS. Weight can provide information about feeding and hydration status, and any significant or sudden changes in weight can indicate a need for further evaluation.
Choice G rationale: Eye contact during feeding can promote bonding between the parent and the newborn. There is no need to avoid eye contact during feeding in a neonate with NAS.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
The weight of the newborn is not a factor in the decision to delay the instillation of antibiotic ophthalmic ointment. The ointment is used to prevent eye infections caused by bacteria present in the mother’s birth canal, and this risk is not related to the newborn’s weight.
Choice B rationale
Whether the newborn was delivered via cesarean birth or vaginal birth does not affect the decision to delay the instillation of antibiotic ophthalmic ointment. The ointment is used to prevent eye infections that can occur regardless of the method of delivery.
Choice C rationale
While it is important to monitor newborns for signs of infection, delaying the instillation of antibiotic ophthalmic ointment would not aid in identifying manifestations of infection. The ointment is a preventative measure and does not interfere with the observation of symptoms.
Choice D rationale
Correct answer. The instillation of antibiotic ophthalmic ointment can cause blurred vision in the newborn. Delaying the instillation of the ointment facilitates immediate bonding between the newborn and parent, as the newborn will be able to see more clearly.
Correct Answer is B
Explanation
Choice A rationale
Obtaining a specimen for a Kleihauer-Betke test is not the immediate action to take when a patient is experiencing a large amount of vaginal bleeding due to uterine atony.
Choice B rationale
Misoprostol is a medication that can be used to treat uterine atony. It helps to contract the uterus and reduce bleeding.
Choice C rationale
Administering betamethasone IM is not the appropriate action. Betamethasone is a steroid medication often used to mature the lungs of a fetus at risk of premature birth, not to treat uterine atony.
Choice D rationale
Avoiding sterile vaginal examinations is not the immediate action to take when a patient is experiencing a large amount of vaginal bleeding due to uterine atony.
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