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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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A rationale
The newborn’s symptoms, such as being jittery with a weak cry when disturbed, mottled extremities with acrocyanosis, and rapid, unlabored respirations, are signs of neonatal abstinence syndrome. This condition can occur in newborns exposed to certain drugs while in the mother’s womb. The first step in managing this condition is to monitor the newborn’s vital

signs. This will help the healthcare team assess the newborn’s condition and determine the appropriate treatment plan. Monitoring vital signs is a crucial part of nursing care, especially for newborns who are showing signs of distress. It provides valuable information about the newborn’s physiological status and response to the environment. Regular monitoring can help detect any changes in the newborn’s condition early, allowing for timely intervention.
Choice B rationale
Swaddling the newborn more tightly is not the best action to take in this situation. While swaddling can provide comfort and help soothe a fussy baby, it is not a treatment for the symptoms the newborn is exhibiting. Furthermore, swaddling should be done correctly to avoid any potential risks such as overheating or hip dysplasia. In this case, the newborn’s symptoms need to be addressed directly, which is why monitoring vital signs is a more appropriate action.
Choice C rationale
Administering oxygen to the newborn is not the most appropriate action based on the symptoms described. While the newborn’s respirations are rapid, they are also unlabored, which suggests that the newborn is not currently experiencing respiratory distress. Oxygen therapy is typically reserved for situations where the newborn is showing signs of respiratory distress, such as grunting, flaring nostrils, or cyanosis around the mouth and tongue. In this case, the acrocyanosis (bluish color of hands and feet) is a common and normal finding in newborns due to immature circulation and is not an indication for oxygen therapy.
Choice D rationale
Notifying the healthcare provider is an important step when caring for a newborn showing signs of distress. However, in this situation, the first action the nurse should take is to monitor

the newborn’s vital signs. This will provide valuable information about the newborn’s current condition that can be reported to the healthcare provider. It’s important for the nurse to gather as much information as possible before contacting the healthcare provider so that they can have a productive discussion about the newborn’s condition and the next steps in their care.

A. Press firmly on the client’s suprapubic area. B. Assist the client in pulling their knees toward their abdomen. C. Apply pressure to the client’s fundus. D. Move the client onto their hands and knees.

Correct Answer is B

Explanation

Choice A rationale
Applying firm pressure on the client’s suprapubic area is not part of the McRoberts maneuver. This action is more associated with the suprapubic pressure technique, which is another method used to manage shoulder dystocia.
Choice B rationale
The McRoberts maneuver involves having the client flex her hips against her abdomen. This is achieved by assisting the client in pulling her knees toward her abdomen.
Choice C rationale
Applying pressure to the client’s fundus is not part of the McRoberts maneuver and can be contraindicated as it may cause additional complications.

Choice D rationale
Moving the client onto their hands and knees is not part of the McRoberts maneuver. This position is more associated with the all-fours maneuver, also known as the Gaskin maneuver.

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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)

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Explanation

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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)