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 D
Explanation
Rationale:
A. A heart rate of 130/min is elevated and may indicate continued dehydration or stress. It does not necessarily indicate the effectiveness of oral rehydration therapy.
B. A capillary refill greater than 3 seconds indicates poor perfusion and ongoing dehydration. It does not indicate the effectiveness of oral rehydration therapy.
C. A respiratory rate of 24/min is within normal range for a 3-year-old child. It does not necessarily indicate the effectiveness of oral rehydration therapy.
D. A urine specific gravity of 1.015 indicates adequate hydration. Normal urine specific gravity typically ranges from 1.005 to 1.030, and a value closer to 1.015 indicates proper hydration
status. Therefore, this finding suggests that oral rehydration therapy has been effective in restoring fluid balance.
Correct Answer is B
Explanation
Rationale:
A. This response doesn't address the client's feelings of fear and reluctance to talk to their parents.
B. This response acknowledges the client's emotions and opens up the conversation for further exploration.
C. While this statement is true, it doesn't address the client's emotional state or concerns.
D. This option dismisses the client's feelings and doesn't offer support or guidance.
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