A nurse is caring for an infant who has signs of neonatal abstinence syndrome. Which of the following actions should the nurse take?

Provide a stimulating environment

Monitor blood glucose level every hour

Initiate seizure precautions

Place the infant on his back with legs extended

Answer and Explanation

The Correct Answer is C

Choice A rationale
Providing a stimulating environment is not recommended for infants with neonatal abstinence syndrome (NAS). These infants often have a heightened response to stimuli, and a calm, quiet environment is usually more beneficial.
Choice B rationale
While it is important to monitor the infant’s overall health, there is no specific need to monitor blood glucose level every hour in infants with NAS unless there is a separate medical indication.
Choice C rationale
Initiating seizure precautions is an appropriate action for a nurse caring for an infant with signs of NAS5. Infants with NAS are at risk for seizures, so nurses should be prepared to manage this potential complication.
Choice D rationale
Placing the infant on his back with legs extended is not recommended. Infants with NAS often have increased muscle tone and may be uncomfortable in this position.

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Correct Answer is C

Explanation

Choice A rationale
Transient strabismus, or temporary misalignment of the eyes, is not typically a symptom observed in newborns exposed to opioids during pregnancy.
Choice B rationale
Mottling, or patchy skin color, is a common physical characteristic in newborns and is not specifically associated with opioid exposure during pregnancy.
Choice C rationale
A respiratory rate of 70/min is significantly higher than the normal range for a newborn, which is typically between 30 and 60 breaths per minute. This could be a sign of neonatal abstinence syndrome (NAS), a group of conditions caused by withdrawal from certain drugs that the newborn was exposed to in the womb.
Choice D rationale
Loose stools are not typically associated with opioid exposure during pregnancy.
Choice E rationale
Regurgitation, or spitting up, is common in newborns and is not specifically associated with opioid exposure during pregnancy.

A. Oxygen saturation of 89% B. Nasal flaring C. Fine crackles D. Apneic episode less than 15 seconds

Correct Answer is A

Explanation

Choice A rationale
An oxygen saturation of 89% in a newborn who was born 2 hours ago and was admitted to the neonatal intensive care unit with chest wall retractions and blue discoloration of the hands and feet indicates a decline in the newborn’s status. This level of oxygen saturation is below the normal range for a newborn, which is typically above 95%10111213. This could indicate that the newborn is not getting enough oxygen, which could be due to a variety of conditions, including respiratory distress syndrome.
Choice B rationale
Nasal flaring is a sign of respiratory distress in a newborn. However, it is a nonspecific sign and does not necessarily indicate a decline in the newborn’s status. It could be a normal response to the newborn’s efforts to breathe more effectively.
Choice C rationale
Fine crackles can be a sign of a lung condition in a newborn. However, they are a nonspecific sign and do not necessarily indicate a decline in the newborn’s status. They could be a normal finding in a newborn who was born 2 hours ago.
Choice D rationale
An apneic episode less than 15 seconds in a newborn who was born 2 hours ago is not necessarily indicative of a decline in the newborn’s status. Brief periods of apnea (pauses in breathing) are common in newborns and are usually not a cause for concern unless they last longer than 20 seconds or are associated with other signs of distress.

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A nurse is caring for an infant who has signs of neonatal abstinence syndrome. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a term newborn who is 48 hours old. The mother has a history of opioid use during pregnancy and was prescribed methadone. Based on the findings 24 hours later, how should the nurse interpret the findings?

Correct Answer is C

Explanation

A nurse is evaluating a newborn who was born 2 hours ago and was admitted to the neonatal intensive care unit with chest wall retractions and blue discoloration of the hands and feet. Which finding indicates a decline in the newborn’s status?

Correct Answer is A

Explanation

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