A nurse is providing care for a newborn suspected of having neonatal abstinence syndrome. Which symptom would support this diagnosis?

Decreased muscle tone

Sleeps for 2 hours after feeding

Continuous high-pitched cry

Mild tremors when disturbed

Answer and Explanation

The Correct Answer is C

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.

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Correct Answer is A

Explanation

Choice A rationale
Monitoring vaginal bleeding is the priority nursing action for a client who is at 33 weeks of gestation and has a diagnosis of placenta previa. Placenta previa can cause painless, bright red vaginal bleeding during the third trimester. This bleeding can lead to serious complications for both the mother and the fetus, making it crucial to monitor for this symptom.
Choice B rationale
Administering glucocorticoids is not the priority nursing action in this situation. While glucocorticoids can be used to accelerate fetal lung maturity in cases of preterm labor, they are not the primary treatment for placenta previa.
Choice C rationale
Inserting an IV catheter may be necessary for administering medications or fluids, but it is not the priority action. The nurse’s primary concern should be monitoring for signs of bleeding.
Choice D rationale
Applying an external fetal monitor can help assess the well-being of the fetus, but it is not the priority action. The nurse’s main focus should be on monitoring for vaginal bleeding.

A. Identifying the level of parental anxiety related to the diagnosis B. Auscultating the rate and characteristics of the child’s heart sounds C. Using a pain-rating tool to evaluate the severity of the joint pain D. Assessing the client’s erythematous rash

Correct Answer is B

Explanation

Choice A rationale
While it’s important to assess the level of parental anxiety related to the diagnosis, it’s not the immediate priority. The child’s physical health needs to be stabilized first.
Choice B rationale
This is the correct answer. Auscultating the rate and characteristics of the child’s heart sounds is the immediate priority. Acute rheumatic fever can lead to serious cardiac complications, so it’s crucial to monitor the child’s heart function closely.
Choice C rationale
While assessing the severity of joint pain is important in managing the child’s comfort, it’s not the immediate priority. The child’s heart function needs to be assessed first.
Choice D rationale
While assessing the client’s erythematous rash is part of the overall assessment of a child with acute rheumatic fever, it’s not the immediate priority. The child’s heart function needs to be assessed first.

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A nurse is providing care for a newborn suspected of having neonatal abstinence syndrome. Which symptom would support this diagnosis?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is admitting a client who is at 33 weeks of gestation and has a diagnosis of placenta previa. What is the priority nursing action?

Correct Answer is A

Explanation

A nurse is attending to an 8-year-old child diagnosed with acute rheumatic fever. What should be the nurse’s immediate priority assessment after admission?

Correct Answer is B

Explanation

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