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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is choiceC. Remove the cap and place it sterile-side up on a clean surface.
Choice A rationale:
Placing sterile gauze over areas of spilled solution within the sterile field is not recommended. Spilled solution can compromise the sterility of the field, and covering it with gauze does not restore sterility. Instead, the nurse should avoid spilling solution to maintain the sterile field.
Choice B rationale:
Holding the irrigation solution bottle with the label facing away from the palm of the hand is incorrect. The correct technique is to hold the bottle with the label facing the palm. This prevents the label from getting wet and unreadable, ensuring that the nurse can always identify the solution correctly.
Choice C rationale:
Removing the cap and placing it sterile-side up on a clean surface is the correct action. This maintains the sterility of the cap, preventing contamination when it is replaced on the bottle. Ensuring the cap remains sterile is crucial for maintaining the sterility of the solution.
Choice D rationale:
Holding the bottle in the center of the sterile field when pouring the solution is incorrect. The bottle should be held outside the sterile field to prevent contamination. The solution should be poured carefully to avoid splashing and compromising the sterile field.
Correct Answer is D
Explanation
The correct answer is choice D, spotting.
Placenta previa is a condition where the placenta implants in the lower part of the uterus, partly or completely covering the cervical opening.
This can cause painless, bright red vaginal bleeding, usually in the third trimester.
Spotting is a sign of placenta previa and should be reported to the provider immediately.
Choice A is wrong because nausea is not a specific finding of placenta previa.
Nausea can occur in normal pregnancy or in other conditions such as hyperemesis gravidarum or preeclampsia.
Choice B is wrong because polyhydramnios is not a finding of placenta previa.
Polyhydramnios is a condition where there is too much amniotic fluid in the uterus, which can cause complications such as preterm labor, cord prolapse, or fetal malformations.
Choice C is wrong because uterine tenderness is not a finding of placenta previa.
Uterine tenderness is a sign of abruptio placentae, which is a condition where the placenta separates from the uterine wall before delivery.
This can cause severe abdominal pain, dark red vaginal bleeding, and fetal distress.
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