A nurse is caring for a newborn who is 72 hr old.
Vital signs
0900:
- Heart rate 160/min
- Respiratory rate 80/min
- Temperature 38.1° C (100.6° F)
- Oxygen saturation 97%
1000:
- Heart rate 167/min
- Respiratory rate 72/min
- Temperature 38°C (100.4°F)
- Oxygen saturation 97%
Medical History
0900:
A term newborn 37 weeks of gestation is admitted to the newborn nursery following a precipitous vaginal birth. Birthing parent has a history of heroin use during pregnancy and prenatal care beginning at 34 weeks of gestation. Birthing parent and newborn drug screens positive for heroin.
The nurse is planning to contact the provider regarding the newborn's status. Which of the following prescriptions should the nurse anticipate? Select the 3 interventions the nurse should anticipate.
Administer oral morphine.
Swaddle the newborn.
Administer naloxone for NAS scores greater than 24.
Encourage the birthing parent to breastfeed.
Continue NAS scoring as prescribed
Correct Answer : A,B,E
A. Administering oral morphine is anticipated because it is used to manage withdrawal symptoms in newborns with Neonatal Abstinence Syndrome (NAS..
B. Swaddling is a non-pharmacological intervention that can provide comfort and reduce overstimulation.
C. Administering naloxone is not typically the first line of treatment for NAS and is used in cases of acute opioid overdose, which is not indicated by the information provided.
D. Encouraging the birthing parent to breastfeed may not be appropriate due to the presence of heroin in the system, which can be transmitted to the newborn through breast milk.
E. Continuing NAS scoring is essential to monitor the newborn's condition and response to treatment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"B"}
Explanation
Meconium aspiration syndrome (MAS) occurs when a newborn breathes in meconium present in the amniotic fluid before or during birth, which can cause respiratory problems. In this case, the presence of meconium-stained fluid, rapid and shallow respiration with occasional expiratory grunting, and fine crackles auscultated throughout lung fields are clinical indicators that suggest the newborn is at risk for MAS.
The newborn is at the greatest risk for meconium aspiration syndrome because meconium-stained fluid was noted during labor. This condition occurs when a newborn inhales a mixture of meconium and amniotic fluid into the lungs, which can lead to respiratory issues such as grunting and fine crackles, both of which were observed in the newborn. It is important for the healthcare team to monitor the baby closely and initiate appropriate interventions to support ventilation and oxygenation as needed.
Correct Answer is C
Explanation
Rationale:
A. Ibuprofen is not recommended for infants younger than six months without specific physician orders due to potential adverse effects.
B. Positioning the infant on her abdomen may not be suitable immediately postoperatively and should be guided by the surgical team's recommendations.
C. Offering a pacifier can provide non-nutritive sucking comfort, which can help soothe the infant and decrease pain perception.
D. While rocking the infant can be comforting, it may not address the immediate postoperative needs of the infant or provide sufficient pain relief.
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