A nurse is performing a physical assessment of a newborn whose mother used cocaine throughout the pregnancy.
Which of the following findings should the nurse expect?
Irritability.
Hypotonicity.
Decreased auditory startle response.
Increased head circumference.
The Correct Answer is A
Choice A rationale:
Irritability is a common withdrawal symptom in newborns exposed to cocaine during pregnancy. Cocaine exposure can lead to irritability, restlessness, and difficulty in consoling the newborn.
Choice B rationale:
Hypotonicity, or decreased muscle tone, is not a common finding associated with cocaine exposure in newborns. Cocaine exposure more commonly results in hypertonicity, where the muscles are tense and rigid.
Choice C rationale:
Decreased auditory startle response is not a typical finding associated with cocaine exposure. Newborns exposed to cocaine may have an exaggerated startle response, which is the opposite of the expected finding in this case.
Choice D rationale:
Increased head circumference is not a characteristic finding associated with cocaine exposure. Cocaine exposure is more likely to cause growth restriction, low birth weight, and microcephaly (small head size) in newborns.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Advocacy is a leadership role that helps others to self-actualize.
- A. Advocacy is a leadership role that helps others to self-actualize. This statement is true and reflects one of the core principles of advocacy, which is to empower others to achieve their full potential and exercise their rights and responsibilities. This choice is correct.
- B. Subordinates are advocates for the nurse manager. This statement is false and contradicts one of the core principles of advocacy, which is to act in the best interest of those who are vulnerable or oppressed, not those who are in positions of power or authority. This choice is incorrect.
- C. Advocacy encourages clients to rely on health care staff for decision-making. This statement is false and contradicts one of the core principles of advocacy, which is to respect and support clients' autonomy and self-determination, not to impose or influence their choices or actions. This choice is incorrect.
- D. Nurse managers should distrust people who expose inappropriate professional practices. This statement is false and contradicts one of the core principles of advocacy, which is to promote and uphold ethical standards and quality of care, not to conceal or ignore malpractice or misconduct. This choice is incorrect.
Correct Answer is ["A","C","E"]
Explanation
Since the client is experiencing upper chest discomfort and coughing up sputum, it is important to assess their oxygen saturation level. This finding can provide vital information about the client's respiratory status and the adequacy of their oxygenation.
The client's report of upper chest discomfort and coughing up thick clear sputum should prompt an assessment of their respiratory rate. Abnormal respiratory rates may indicate respiratory distress or compromise, which requires immediate attention.
Assessing the client's current level of consciousness is crucial, as any sudden changes in their mental status may indicate a serious underlying issue. Since the client has a history of Parkinson's disease and reported "feeling bad," it is important to evaluate their neurological status promptly.
The other options listed (tremors, heart rate, and chronic health condition) may also require follow-up, but they are not the most immediate concerns in this situation.
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