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 A
Explanation
A.
Rationale:
A. Breast tenderness:
Correct answer. Clomiphene citrate, a medication used to induce ovulation, can cause breast tenderness as a common adverse effect due to its estrogenic effects.
B. Chills: Chills are not a common adverse effect of clomiphene citrate.
C. Tinnitus: Tinnitus, or ringing in the ears, is not typically associated with clomiphene citrate use.
D. Urinary frequency: Urinary frequency is not a common adverse effect of clomiphene citrate.
Correct Answer is A
Explanation
A.
Rationale:
A. Maternal cytomegalovirus can be transmitted to the newborn through contact with infected bodily fluids, including saliva and urine.
B. Airborne precautions are not necessary for cytomegalovirus, as it is primarily transmitted through contact with infected bodily fluids, not through airborne droplets.
C. There is no prophylactic treatment with acyclovir for cytomegalovirus; treatment options are limited and typically reserved for severe cases.
D. Lesions are not typically visible on the mother's genitalia with cytomegalovirus; the virus is often asymptomatic or causes mild symptoms in healthy adults.
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