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

The mother used opioids prior to pregnancy and was prescribed methadone during pregnancy. Both the mother and the newborn tested positive for methadone in their urine drug screens.

The newborn is exhibiting clinical findings of neonatal abstinence syndrome (NAS). Which of the following actions should the nurse take? Select all that apply.

Maintain a low stimulation environment

Weigh the newborn daily

Advise the parent to avoid breastfeeding

Avoid eye contact with the newborn during feeding

Plan to administer naloxone

Swaddle the newborn with flexed extremities

Perform Ballard newborn screening each shift . .

Answer and Explanation

Correct Answer : A,B,F

Choice A rationale
Maintaining a low-stimulation environment is recommended for newborns exhibiting clinical findings of NAS56. This can help to reduce symptoms such as irritability and restlessness.
Choice B rationale
Weighing the newborn daily is important in the care of a newborn with NAS56. This can help to monitor the newborn’s growth and development, and any significant changes in weight could indicate a need for further medical intervention.
Choice C rationale
Advising the parent to avoid breastfeeding is not typically recommended for mothers who used opioids prior to pregnancy and were prescribed methadone during pregnancy. In fact, breastfeeding is often encouraged for these mothers, as it can help to reduce the severity of NAS symptoms in the newborn.
Choice D rationale
Avoiding eye contact with the newborn during feeding is not typically recommended as part of the care for a newborn with NAS56. Eye contact can help to promote bonding between the parent and the newborn.
Choice E rationale
The administration of naloxone is not typically recommended for a newborn with NAS56. Naloxone is a medication used to reverse the effects of opioids, but it is not typically used in the treatment of NAS56.
Choice F rationale
Swaddling the newborn with flexed extremities can help to comfort a newborn with NAS56. This can help to reduce symptoms such as irritability and restlessness.
Choice G rationale
This option is not typically necessary for the management of neonatal abstinence syndrome (NAS). The Ballard score is used to assess gestational age and physical maturity of a newborn, but it is not a routine part of monitoring for NAS.

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Correct Answer is D

Explanation

Choice A rationale
Amniocentesis is not a surgical procedure that requires general anesthesia, so the client will not be asleep during the procedure.
Choice B rationale
Fasting is not typically required before an amniocentesis. The procedure involves inserting a thin needle into the amniotic sac to withdraw a small amount of fluid for testing. It does not involve the digestive system, so there is no need for the client to fast.
Choice C rationale
While the client may be in various positions during the procedure, lying on the side is not typically required. The position of the client during the procedure is determined by the location of the baby and the amniotic sac.
Choice D rationale
Emptying the bladder before the procedure can make it easier for the healthcare provider to access the uterus and amniotic sac. Therefore, this statement indicates an understanding of the teaching.

A. Position the client supine with knees flexed and place a small, rolled towel under one of their hips. B. Palpate the fetal part positioned above the symphysis pubis. C. Instruct the client to empty their bladder. D. Palpate the fetal part positioned in the fundus. E. Palpate the fetal parts along both sides of the uterus.

Correct Answer is C, A, D, E, B

Explanation

The Leopold maneuvers are a common and systematic way to determine the position of a fetus inside the woman’s uterus. They are typically performed at prenatal examinations during the third trimester of pregnancy. Here is the correct sequence of actions a nurse should take: Instruct the client to empty their bladder. This is done to make the examination easier and more comfortable for the client ©. Position the client supine with knees flexed and place a small, rolled towel under one of their hips. This position helps relax the abdominal muscles and displaces the uterus to the side, reducing the risk of supine hypotensive syndrome (a). Palpate the fetal part positioned in the fundus. This helps determine the fetal lie and presentation (d). Palpate the fetal parts along both sides of the uterus. This helps identify the location of the fetal back and small parts (e). Palpate the fetal part positioned above the symphysis pubis. This helps determine the fetal attitude and degree of extension or flexion of the fetal head (b). Remember, these maneuvers should be performed gently and respectfully, with the nurse explaining each step to the client. The goal is to assess the position and presentation of the fetus, as well as estimate fetal weight, not to change the position of the fetus. If the nurse is unsure about the position or presentation of the fetus, an ultrasound may be needed for confirmation.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing teaching to a client who is at 35 weeks of gestation and has a prescription for an amniocentesis. Which of the following client statements indicates an understanding of the teaching?

Correct Answer is D

Explanation

A nurse is preparing to perform Leopold maneuvers on a client who is at 36 weeks of gestation. Identify the sequence of actions the nurse should take.

Correct Answer is C, A, D, E, B

Explanation

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