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 A

Explanation

The correct answer is choice A, administer a fluid bolus.

Choice A rationale:

Administering a fluid bolus is appropriate when a client’s urine output is low, which in this case is less than the minimum expected output of 30 mL/hr. The dark yellow color of the urine also suggests dehydration or concentrated urine, which can be addressed with increased fluid intake.

Choice B rationale:

Initiating continuous bladder irrigation is typically done to clear the urinary tract of blood clots or debris following urologic surgery, not for low urine output or dark urine. Therefore, this intervention is not indicated based on the given scenario.

Choice C rationale:

Obtaining a urine specimen for culture and sensitivity is an action taken when there is a suspicion of a urinary tract infection. The scenario does not provide evidence of infection, such as fever or cloudy urine with a strong odor, so this would not be the first intervention to anticipate.

Choice D rationale:

Clamping the catheter tubing is done in preparation for catheter removal or to assess if the client can void without the catheter. It is not an appropriate intervention for low urine output or dark urine and could potentially cause bladder distention or discomfort.

A. Allow the client to choose among a variety of activities each day. B. Give the client one simple direction at a time. C. Reinforce orientation to time, place, and person. D. Establish eye contact when communicating with the client. E. Refute the client’s delusions using logic.

Correct Answer is ["B","C","D"]

Explanation

The correct answer is choice B, C, and D. The nurse should give the client one simple direction at a time, reinforce orientation to time, place, and person, and establish eye contact when communicating with the client.

These interventions can help the client with dementia to understand and follow instructions, reduce confusion and anxiety, and enhance communication.

Choice A is wrong because allowing the client to choose among a variety of activities each day can overwhelm and frustrate the client with dementia.

The nurse should provide a structured and consistent daily routine for the client.

Choice E is wrong because refuting the client’s delusions using logic can increase the client’s agitation and distrust.

The nurse should use validation therapy to acknowledge the client’s feelings and emotions without arguing or correcting the client.

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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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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?