A nurse is caring for a newborn who is 5 days old.
Medical History
History of maternal opioid use prior to pregnancy and prescribed methadone use during pregnancy. Maternal and neonatal positive urine drug screens for methadone. 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.
Plan to administer naloxone.
Instruct the parent to avoid breastfeeding
Instruct the parent to avoid eye contact with the newborn during feeding
Perform Ballard newborn screening each shift.
Weigh the newborn daily.
Swaddle the newborn with flexed extremities
Correct Answer : A,C,E,F,G
Rationale:
A. Newborns with neonatal abstinence syndrome (NAS) are often irritable and hypersensitive to stimuli. Keeping the environment calm and quiet can help minimize their discomfort.
B. Naloxone is not routinely used in the management of NAS unless there is evidence of severe respiratory depression or opioid overdose, which is not indicated in this scenario.
C. Maternal opioid use and positive urine drug screens for methadone may contraindicate breastfeeding due to the potential transmission of opioids to the infant through breast milk. It's essential to consult with healthcare providers regarding the safest feeding option for the newborn.
D. Eye contact during feeding is essential for bonding between the parent and the newborn and should not be discouraged unless medically necessary.
E. Ballard newborn screening helps assess the newborn's gestational age and guide appropriate care for neonates with NAS, as they may require specialized management.
F. Daily weighing helps monitor the newborn's hydration status and overall well-being, which is crucial in managing NAS and ensuring adequate nutrition.
G. Swaddling can provide comfort to newborns with NAS by mimicking the womb environment and reducing their agitation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. Using Naegle’s rule, May 3rd isn’t the correct answer
B. Using Naegle’s rule, May 20th isn’t the correct answer
C. Using Naegle’s rule, May 13th isn’t the correct answer
D. This is the correct answer Using Nägele's Rule:
1. Determine the first day of the last menstrual period (LMP): August 10.
2. Subtract 3 months: August - 3 months = May.
3. Add 7 days: May 10 + 7 days = May 17.
Correct Answer is {"A":{"answers":"C"},"B":{"answers":"C"},"C":{"answers":"B"},"D":{"answers":"C"},"E":{"answers":"C"},"F":{"answers":"B"}}
Explanation
Leukocytosis: Indication of Worsening Condition - Leukocytosis, an increase in white blood cell count, may indicate an exacerbation of the deep vein thrombosis or the development of an infection.
Redness in the extremity: Indication of Worsening Condition - Redness in the extremity suggests inflammation or worsening of the deep vein thrombosis.
Scant lochia rubra: Indication of Improving Condition - Scant lochia rubra indicates a decrease in postpartum bleeding, which is a positive sign.
Increased warmth in the extremity: Indication of Worsening Condition - Increased warmth in the extremity suggests increased inflammation and may indicate progression of the deep vein thrombosis.
Tachycardia: Indication of Worsening Condition - Tachycardia, an elevated heart rate, can be a sign of worsening condition, possibly due to complications such as pulmonary embolism.
Decreased extremity edema: Indication of Improving Condition - Decreased extremity edema suggests reduced swelling, which is a positive sign indicating improvement in circulation and reduction of fluid accumulation in the affected limb.
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