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 C
Explanation
Rationale:
A. A WBC count of 11,000/mm3 is slightly elevated but may be within normal limits, as the normal range for WBC count can vary slightly depending on the laboratory. It is not typically concerning during pregnancy.
B. A hematocrit of 37% is within the normal range for pregnancy (37% to 47%) and does not require immediate reporting to the provider.
C. A fasting blood glucose level of 180 mg/dL is significantly elevated and indicates hyperglycemia, which may be indicative of gestational diabetes mellitus or pre-existing diabetes. This finding should be reported to the provider for further evaluation and management.
D. A creatinine level of 0.9 mg/dL is within the normal range (0.5 to 1 mg/dL) and does not require immediate reporting to the provider.
Correct Answer is C
Explanation
Rationale:
A. Airborne precautions are used for diseases transmitted by airborne droplet nuclei smaller than 5 microns, such as tuberculosis. MRSA is not transmitted via airborne route.
B. Protective environment is used for clients who are immunocompromised, such as those undergoing bone marrow transplantation. It is not indicated for MRS
A.
C. Contact precautions are indicated for MRSA, as it is primarily transmitted through direct or indirect contact with an infected individual or contaminated environment.
D. Droplet precautions are used for diseases transmitted by large droplets (>5 microns), such as influenza or pertussis. MRSA is not transmitted via droplets.
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