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 A
Explanation
A. Glucose
Rationale:
A. Glucose monitoring is essential for clients with polycystic ovarian syndrome (PCOS) due to the increased risk of insulin resistance and diabetes.
B. Blood urea nitrogen (BUN) levels are not typically monitored specifically for PCOS.
C. Thyroid-stimulating hormone (TSH) levels may be assessed if there is suspicion of thyroid dysfunction but are not routinely monitored for PCOS.
D. Liver function tests are not typically indicated for routine monitoring in PCOS unless there are specific signs or symptoms of liver dysfunction.
Correct Answer is D
Explanation
Rationale:
A. "Your baby should sleep at least 6 hours between feedings.": Newborns typically wake every 2-3 hours for feeding, so sleeping for 6 hours between feedings is not indicative of adequate breastfeeding.
B. "Your baby should burp after each feeding.": Burping is important for gas relief but does not necessarily indicate sufficient breastfeeding.
C. "Your baby should have a wake cycle of 30 to 60 minutes after each feeding.": The wake cycle after feeding is not a reliable indicator of sufficient breastfeeding.
D. "Your baby should wet 6 to 8 diapers per day.": Monitoring the number of wet diapers is a
reliable indicator of adequate breastfeeding. A newborn who is getting enough breast milk should produce at least 6 to 8 wet diapers per day, indicating sufficient hydration and nutrient intake.
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