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. Preterm delivery: While preterm delivery can result in low birth weight, it is not typically considered a direct cause of being small for gestational age (SGA). SGA infants are generally small because of intrauterine growth restriction rather than preterm birth.
B. Fetal hyperinsulinemia: Fetal hyperinsulinemia may lead to macrosomia (large for gestational age) rather than SG
A.
C. Perinatal asphyxia: Perinatal asphyxia refers to oxygen deprivation around the time of birth and is not typically associated with SG
A.
D. Placental insufficiency: Placental insufficiency, resulting in poor nutrient and oxygen transfer to the fetus, is a common cause of SG
A. Insufficient placental function can limit fetal growth,
leading to a newborn being small for their gestational age.
Correct Answer is C
Explanation
Rationale:
A. Panting may be indicated if pushing is premature, but the sudden urge to push suggests the need to assess for crowning.
B. While assisting the client into a comfortable position may be appropriate, it's essential to first assess for signs of imminent delivery.
C. This action is crucial to determine if the client is fully dilated and ready for delivery.
D. Helping the client to void may relieve pressure on the bladder but does not address the sudden urge to push, which may indicate imminent delivery.
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