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 D
Explanation
The correct answer is choice D. Sit with the client to provide a sense of security.
A client who is experiencing a panic attack has a very high level of anxiety and a diminished ability to focus.
The nurse should stay with the client and remain calm and reassuring during the panic attack. This can help the client feel safe and supported, and reduce the intensity of the anxiety.
Choice A is wrong because atomoxetine is not an anti-anxiety medication, but a selective norepinephrine reuptake inhibitor (SNRI) used to treat attention deficit hyperactivity disorder (ADHD). It has no effect on reducing anxiety and can cause side effects such as insomnia, nausea, and increased blood pressure.
Choice B is wrong because encouraging the client to watch television is not a therapeutic intervention for a panic attack.
Watching television can increase the stimuli in the client’s environment, which can worsen the anxiety.
The nurse should maintain an environment with low stimulation for the client experiencing a panic attack. Dim lighting, few people, and minimal distractions can assist the nurse to decrease the client’s level of anxiety.
Choice C is wrong because teaching the client how to meditate is not appropriate during a panic attack.
Meditation is a relaxation technique that can be helpful for preventing or reducing anxiety, but it requires concentration and focus, which are impaired in a panic attack. The nurse should teach the client how to meditate when the client is calm and receptive, not when the client is in crisis.
Correct Answer is B
Explanation
The correct answer is choice B. Determine the client’s knowledge about diaphragm use. This is the first action the nurse should take because it allows the nurse to assess the client’s readiness to learn, identify any knowledge gaps, and tailor the teaching to the client’s needs.
Some of the other choices are wrong because:
- Choice A. Supervise return demonstration of diaphragm use.
This is not the first action the nurse should take because it assumes that the client already knows how to use the diaphragm correctly and safely. The nurse should first teach the client how to insert, remove, and care for the diaphragm before asking for a return demonstration.
- Choice C. Document the client’s level of understanding about potential adverse effects.
This is not the first action the nurse should take because it is part of the evaluation phase of teaching, not the assessment phase. The nurse should first determine what the client knows and needs to know about diaphragm use and its possible risks and benefits.
- Choice D. Teach the client how to insert the diaphragm.
This is not the first action the nurse should take because it is part of the implementation phase of teaching, not the assessment phase. The nurse should first assess the client’s knowledge, motivation, and preferences before providing instruction on how to use the diaphragm.
A contraceptive diaphragm is a birth control device that prevents sperm from entering the uterus.
It is a small, soft silicone or rubber cup with a flexible rim that covers the cervix.
It is inserted into the vagina with spermicide before sex and is held in place by the pelvic muscles. It is a reusable type of contraception that women can use to avoid getting pregnant.
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