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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 C

Explanation

Choice A rationale
Asking when the client last ate meat is not relevant for assessing dietary intake in a client who adheres to a vegan diet. Vegans do not consume meat or any other animal products.
Choice B rationale
While vitamin C is an important nutrient, it is not typically a concern for vegans as it is abundant in fruits and vegetables. Therefore, asking about vitamin C supplementation may not provide the most useful information about the client’s dietary intake.
Choice C rationale
Protein intake is a key concern for individuals following a vegan diet, as many sources of protein are animal-based. Vegans can get protein from foods like lentils, chickpeas, beans, tofu, and nuts. Therefore, asking about daily protein intake can provide valuable information about the client’s dietary habits and nutritional status.
Choice D rationale
Shellfish are not part of a vegan diet, so asking if the client has considered eating shellfish would not be relevant or appropriate.

A. Preterm newborns might have a thick layer of brown fat that can cause them to quickly become overheated. B. Preterm newborns might shiver to warm up when they get too cool. C. Preterm newborns might sweat to cool off when they get too warm. D. Preterm newborns might have less muscle tone which exposes more body surfaces to heat loss.

Correct Answer is D

Explanation

Choice A rationale
Preterm newborns do not have a thick layer of brown fat. Brown fat is a type of fat that generates heat and is typically found in full-term newborns. It helps them maintain their body temperature. Preterm newborns have less brown fat, which makes them more susceptible to hypothermia.
Choice B rationale
Shivering is a mechanism used by the body to generate heat when it’s cold. However, preterm newborns cannot shiver. Their nervous systems are not fully developed, and they lack the muscle coordination necessary to shiver.
Choice C rationale
Sweating is another mechanism the body uses to regulate temperature. When the body is too warm, it produces sweat to cool down. However, preterm newborns do not sweat to cool off when they get too warm. Their sweat glands are not fully developed, and they may not be able to sweat effectively.
Choice D rationale
Preterm newborns have less muscle tone, which exposes more body surfaces to heat loss. Muscle tone provides insulation and generates heat. Because preterm newborns have less muscle mass, they have less insulation and generate less heat, making them more susceptible to hypothermia.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who is at 6 weeks of gestation and adheres to a vegan diet. Which of the following Questions should the nurse ask to assess the client’s dietary intake?

Correct Answer is C

Explanation

A nurse is providing teaching to the guardians of a preterm newborn about temperature instability. Which of the following statements should the nurse make?

Correct Answer is D

Explanation

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