A nurse is caring for a newborn whose mother was taking methadone during her pregnancy.

Which of the following findings indicates the newborn is experiencing withdrawal?

Acrocyanosis

Bradycardia

Bulging fontanels

Hypertonicity

Answer and Explanation

The Correct Answer is D

Hypertonicity is a sign of increased muscle tone and stiffness, which can indicate that the newborn is experiencing withdrawal from methadone exposure in utero. Methadone is an opioid medication that can cross the placenta and cause neonatal abstinence syndrome (NAS) in the newborn.

Choice A, acrocyanosis, is wrong because it is a normal finding in newborns.

Acrocyanosis is a bluish discoloration of the hands and feet due to immature peripheral circulation. It usually resolves within the first 24 to 48 hours of life.

Choice B, bradycardia, is wrong because it is not a typical sign of withdrawal.

Bradycardia is a slow heart rate, usually less than 100 beats per minute in newborns. It can be caused by hypoxia, hypothermia, hypoglycemia, or vagal stimulation.

Choice C, bulging fontanels, is wrong because it is a sign of increased intracranial pressure, not withdrawal. Bulging fontanels can be caused by meningitis, hydrocephalus, or hemorrhage.

Normal ranges for newborn vital signs are as follows:

Heart rate: 120 to 160 beats per minute
Respiratory rate: 30 to 60 breaths per minute
Temperature: 36.5 to 37.5°C (97.7 to 99.5°F)
Blood pressure: 60 to 80 mm Hg systolic and 40 to 50 mm Hg diastolic

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Correct Answer is C

Explanation

This statement should be included in the hand-off report because it provides essential information about the patient’s intraoperative status and potential postoperative complications, such as hypovolemia, anemia, or infection. The estimated blood loss (EBL) is an important indicator of the patient’s fluid balance and hemodynamic stability.

Choice A is wrong because “The client was intubated without complications.” is not relevant for the postoperative care of the patient. The intubation status is usually documented in the anesthesia record and does not need to be repeated in the hand-off report unless there were any issues or injuries related to the airway management.

Choice B is wrong because “There was a total of 10 sponges used during the procedure.” is not pertinent for the postoperative care of the patient.

The number of sponges used during the surgery is usually counted and verified by the scrub nurse and the circulating nurse in the operating room to prevent any retained foreign bodies. This information does not need to be communicated to the PACU nurse unless there was a discrepancy or a missing sponge.

Choice D is wrong because “The client is a member of the board of directors.” is not appropriate for the hand-off report.

This statement violates the patient’s privacy and confidentiality and does not contribute to the quality or safety of care. The patient’s role or position in the organization should not influence the hand-off communication or the postoperative care.

A hand-off report is a critical communication tool that facilitates the transfer of care from one provider to another. It should include relevant information about the patient’s medical history, surgical procedure, intraoperative events, postoperative plan, and any concerns or potential problems.

A standardized hand-off tool, such as SBAR (Situation, Background, Assessment, Recommendation), can help improve the consistency, accuracy, and completeness of the hand-off report.

Some normal ranges that may be useful for postoperative care are:

Blood pressure: 90/60 mmHg to 120/80 mmHg
Pulse: 60 to 100 beats/min
Respiratory rate: 12 to 20 breaths/min
Oxygen saturation: 95% to 100%
Temperature: 36°C to 37.5°C
Hemoglobin: 12 to 18 g/dL
Hematocrit: 36% to 54%

A. Monitor the client’s urine output B. Check the client for nasal congestion C. Evaluate the client for orthostatic hypotension D. Obtain the client’s laboratory results

Correct Answer is C

Explanation

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A nurse is caring for a newborn whose mother was taking methadone during her pregnancy. Which of the following findings indicates the newborn is experiencing withdrawal?

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A nurse is caring for a newborn whose mother was taking methadone during her pregnancy.

Which of the following findings indicates the newborn is experiencing withdrawal?