A nurse is preparing to measure an infant’s vital signs.

Which of the following sites should the nurse use to assess the heart rate?

Choice A rationale
Decreased muscle tone is not typically associated with neonatal abstinence syndrome (NAS). NAS is a condition that affects newborns who have been exposed to addictive opiate drugs while in the mother’s womb.
Choice B rationale
Sleeping for 2 hours after feeding is not a specific symptom of NAS. While changes in sleep patterns can occur in NAS, they are not definitive indicators of the condition.
Choice C rationale
A continuous high-pitched cry is a common symptom of NAS123. This is because the baby is going through withdrawal from the drugs they were exposed to in the womb.
Choice D rationale
Mild tremors when disturbed are indeed a symptom of NAS123. However, this symptom alone is not enough to diagnose NAS as it can be seen in other conditions as well.

Choice A rationale
Hydration is crucial for children who have recovered from an acute crisis episode of sickle cell anemia. Dehydration can increase the risk of a sickle cell crisis by making the blood more concentrated. Offering fluids to the child multiple times every day can help prevent dehydration.
Choice B rationale
Monitoring the child’s temperature daily can help detect any infections early. Infections can trigger a sickle cell crisis. However, this is not the most critical instruction for the nurse to include in the teaching.
Choice C rationale
Applying cold compresses when the child expresses pain is not recommended. Cold can cause vasoconstriction, which can lead to a decrease in blood flow and potentially trigger a sickle cell crisis.
Choice D rationale
Restricting outdoor play activity to 1 hour per day is not necessarily required for children who have recovered from an acute crisis episode of sickle cell anemia. Physical activity is generally beneficial for children’s health and well-being.