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. Administering methylergonovine is not appropriate for a fourth-degree perineal laceration.
Methylergonovine is typically used to prevent or treat postpartum hemorrhage by promoting uterine contractions.
B. Applying povidone-iodine to the client's perineum is not indicated for the management of a perineal laceration. Povidone-iodine is an antiseptic solution used for wound cleansing, but it may be too harsh for the perineal area.
C. Providing the client with a cool sitz bath is appropriate for managing discomfort and promoting healing after a fourth-degree perineal laceration. A sitz bath helps to soothe the perineal area and reduces inflammation.
D. Applying a moist, warm compress to the perineum is not recommended for a fourth-degree perineal laceration, as it may increase the risk of infection and discomfort.
Correct Answer is A
Explanation
A. "The car seat should be positioned in the car at a 45-degree angle." This statement is correct and indicates an understanding of car seat safety. Positioning the car seat at a 45-degree angle helps prevent the newborn's head from flopping forward, which could obstruct the airway. Proper positioning ensures both safety and comfort during travel.
B. "My baby will need a car seat challenge test before discharge." This statement is incorrect for a newborn delivered at 38 weeks of gestation. A car seat challenge test is typically required for premature infants (less than 37 weeks gestation) or those with specific health conditions to ensure they can tolerate sitting in a car seat without respiratory or cardiac issues.
C. "When my baby is 1 year old, I can turn their car seat facing forward." Incorrect. It is recommended to keep infants in a rear-facing car seat until they reach the maximum height or weight limit recommended by the car seat manufacturer, typically well beyond the first year of life.
D. “I can use a sleep sack to keep my baby warm in the car seat." While using a sleep sack can keep a baby warm, it's important not to use any additional padding or blankets in the car seat as they can interfere with the proper harness fit and increase the risk of injury in the event of a crash.
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