A nurse is caring for a newborn who is experiencing neonatal abstinence syndrome. Which of the following actions should the nurse take?
Provide frequent stimulation for the newborn.
Encourage frequent eye contact with the newborn during feedings.
Decrease the lighting levels in the nursery.
Wrap the newborn loosely in a blanket
The Correct Answer is C
A. Provide frequent stimulation for the newborn. Excessive stimulation can worsen symptoms in newborns with neonatal abstinence syndrome (NAS), including irritability, tremors, and difficulty sleeping. These infants need a calm, low-stimulation environment to reduce neurologic stress.
B. Encourage frequent eye contact with the newborn during feedings. While bonding is important, prolonged or forced eye contact can overstimulate a newborn with NAS. These infants often have difficulty regulating sensory input and may become more irritable with excessive interaction.
C. Decrease the lighting levels in the nursery. A dim, quiet environment helps soothe infants experiencing NAS. Reducing lighting can minimize sensory overload, promote rest, and support neurologic regulation during withdrawal.
D. Wrap the newborn loosely in a blanket. Loose wrapping does not provide the security and containment that helps calm an overstimulated infant. Instead, swaddling the newborn snugly can reduce tremors, promote sleep, and offer comfort during withdrawal symptoms.
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Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"}}
Explanation
- Provide the client with high-calorie fluids every hr: Clients in manic states often experience poor nutritional intake due to hyperactivity and distractibility. Frequent, easy-to-consume high-calorie fluids help support caloric and hydration needs without requiring the client to sit for meals, making this an appropriate intervention.
- Minimize environmental stimuli for the client: Clients experiencing mania are often overstimulated and agitated due to their heightened sensitivity and rapid thought processes. A low-stimulation environment helps reduce agitation, prevent escalation, and promote safety.
- Weigh the client each day: While weight monitoring may be important in some psychiatric or medical conditions, daily weights are not a priority in the acute management of mania, particularly when the client is hyperactive, distracted, and unable to participate reliably. This could also increase agitation or preoccupation in some clients.
- Encourage the client to avoid napping during the day: Manic clients often suffer from significantly reduced sleep, which contributes to worsening symptoms. Encouraging rest and short naps would be more therapeutic than promoting wakefulness, so avoiding naps is contraindicated in this scenario.
Correct Answer is D
Explanation
A. "I will plan to spend time tanning between 10 a.m. and 2 p.m." UV radiation from the sun is strongest between 10 a.m. and 4 p.m., and sun exposure during this time significantly increases the risk of skin cancer. Outdoor activity should be minimized during peak hours.
B. "I will use an indoor tanning bed instead of going outside." Indoor tanning beds expose users to intense UV radiation, which also increases the risk of skin cancer. They are not a safer alternative to natural sunlight and should be avoided.
C. "I will use sunblock with an SPF of 10 when I am outdoors." SPF 10 provides minimal protection and is not adequate for skin cancer prevention. The recommended SPF is 30 or higher, applied generously and re-applied regularly.
D. "I will apply sunscreen before and after swimming." Sunscreen should be applied 15 to 30 minutes before sun exposure and re-applied every 2 hours, especially after swimming or sweating. This statement shows an understanding of proper sun protection practices.
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