A nurse is developing a plan of care for a newborn whose mother tested positive for heroin during pregnancy.

The newborn is experiencing neonatal abstinence syndrome.

Which of the following actions should the nurse include in the plan?

Swaddle the newborn with his legs extended.

Administer naloxone to the newborn

Maintain eye contact with the newborn during feedings

Minimize noise in the newborn’s environment

Answer and Explanation

The Correct Answer is D

The correct answer is choice D. Minimize noise in the newborn’s environment.

This is because neonatal abstinence syndrome (NAS) is a condition that affects newborns who are exposed to opioids or other addictive substances in the womb. These substances can cause withdrawal symptoms in the newborns, such as excessive crying, tremors, vomiting, diarrhea, and seizures.

Minimizing noise and other stimuli can help calm the newborn and reduce stress.

Choice A is wrong because swaddling the newborn with his legs extended can increase muscle tension and discomfort. Swaddling should be done with the legs flexed and hips abducted to prevent hip dysplasia.

Choice B is wrong because administering naloxone to the newborn can cause severe withdrawal symptoms and respiratory depression. Naloxone is an opioid antagonist that reverses the effects of opioids, but it is not recommended for newborns with NAS unless they have life-threatening respiratory depression.

Choice C is wrong because maintaining eye contact with the newborn during feedings can overstimulate the newborn and cause agitation. Eye contact should be avoided or limited during feedings for newborns with NAS.

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Correct Answer is A

Explanation

The correct answer is choice a. Maternal hypoglycemia.

Choice A rationale:

Maternal hypoglycemia can lead to fetal bradycardia, causing a sustained low fetal heart rate. Hypoglycemia in the mother can affect the fetus by reducing the availability of glucose, which is essential for fetal metabolism and heart function.

Choice B rationale:

Maternal fever is more commonly associated with fetal tachycardia rather than bradycardia. Fever in the mother can lead to an increased fetal heart rate, not a decreased one.

Choice C rationale:

Chorioamnionitis is an infection of the fetal membranes and amniotic fluid, which can lead to fetal distress and tachycardia rather than bradycardia.

Choice D rationale:

Fetal anemia can also cause bradycardia, but in this scenario, maternal hypoglycemia is a more immediate concern as it directly affects the fetal heart rate by impacting the fetal metabolic processes.

A. Elevated pain level. B. Increased drowsiness. C. Frequent swallowing. D. Diminished breath sounds.

Correct Answer is C

Explanation

The correct answer is choice C, frequent swallowing.

This indicates that the child may be experiencing hemorrhage because they are trying to clear the blood from their throat. Frequent swallowing is one of the initial signs of bleeding immediately after tonsillectomy.

Choice A is wrong because elevated pain level is not a specific sign of hemorrhage.

Pain is expected after a tonsillectomy and can be managed with medication and fluids.

Choice B is wrong because increased drowsiness is not a specific sign of hemorrhage.

Drowsiness can be caused by anesthesia, medication, or dehydration.

Choice D is wrong because diminished breath sounds are not a specific sign of hemorrhage.

Diminished breath sounds can be caused by respiratory infection, asthma, or bronchospasm.

Normal ranges for hemoglobin and hematocrit are 11.5 to 15.5 g/dL and 34 to 45% for children, respectively.

Normal ranges for platelet count are 150,000 to 450,000/mm3 for both children and adults.

Normal ranges for plasma clotting variables depend on the specific test and method used.

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A nurse is developing a plan of care for a newborn whose mother tested positive for heroin during pregnancy. The newborn is experiencing neonatal abstinence syndrome. Which of the following actions should the nurse include in the plan?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is C

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A nurse is developing a plan of care for a newborn whose mother tested positive for heroin during pregnancy.

The newborn is experiencing neonatal abstinence syndrome.

Which of the following actions should the nurse include in the plan?