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
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
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is choice C, malaise.
Malaise is a general feeling of discomfort, weakness, or illness that can be a sign of infection. According to the health search result from Focus Medica , bacterial pneumonia is an infection of the air sacs in one or both lungs that causes symptoms such as cough with phlegm, fever, chills, and difficulty breathing.
Malaise is one of the symptoms that may follow these signs of infection.
Choice A, drooling, is wrong because it is not a typical symptom of bacterial pneumonia.
Drooling can be caused by other conditions, such as sore throat, dental problems, or neurological disorders.
Choice B, tinnitus, is wrong because it is not a symptom of bacterial pneumonia either.
Tinnitus is a ringing or buzzing sound in the ears that can be caused by exposure to loud noise, ear infections, or other ear problems.
Choice D, rhinorrhea, is wrong because it is not specific to bacterial pneumonia.
Rhinorrhea is a runny nose that can be caused by many factors, such as allergies, colds, or sinus infections.
Rhinorrhea can sometimes occur with viral pneumonia, but not usually with bacterial pneumonia.
Correct Answer is D
Explanation
The correct answer is choice D. This test should be performed after your baby is 24 hours old. This is because newborn genetic screening is a set of laboratory tests that detect a set of known genetic diseases that can affect a child’s long-term health or survival. The test is performed on a blood sample obtained from a heel prick when the baby is two or three days old. Performing the test after 24 hours ensures that the baby has had enough time to metabolize certain substances that could interfere with the accuracy of the test.
Choice A is wrong because the blood sample is not drawn from the baby’s inner elbow, but from the heel. Choice B is wrong because the baby does not need to drink water prior to the test, as this could dilute the blood sample and affect the results. Choice C is wrong because the test does not need to be repeated when the baby is 2 months old, unless there is a positive or inconclusive result from the first test.
Newborn genetic screening is important for early detection and intervention of certain conditions that can cause serious health problems or disability if left untreated. Parents should be informed about the benefits and limitations of the test, as well as their rights and options regarding consent and confidentiality.
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