A nurse is reinforcing discharging teaching with a client who is 2 days postpartum. Which of the following statements should the nurse include in the teaching?

Choice A:

Blood pressure is not a priority finding for a newborn with neonatal abstinence syndrome (NAS). Blood pressure may be slightly elevated or normal in NAS, but it is not a sign of severe withdrawal or a risk for complications. •

Choice B:

Gastrointestinal disturbances are common and serious symptoms of NAS. They include poor feeding, vomiting, diarrhea, dehydration and poor weight gain. These can lead to electrolyte imbalance, malnutrition and failure to thrive. This choice requires immediate follow-up. •

Choice C:

Skin color is not a priority finding for a newborn with NAS. Skin color may be normal or slightly pale in NAS, but it is not a sign of severe withdrawal or risk for complications. •

Choice D:

NAS score is a priority finding for a newborn with NAS. NAS score is a tool used to assess the severity of withdrawal symptoms and the need for pharmacological treatment. A high NAS score indicates that the newborn needs medication to manage the withdrawal and prevent complications such as seizures. This choice requires immediate follow-up. •

Choice E:

Temperature is not a priority finding for a newborn with NAS. The temperature may be slightly elevated or normal in NAS, but it is not a sign of severe withdrawal or risk for complications. •

Choice F:

Oxygen saturation is a priority finding for a newborn with NAS. Oxygen saturation measures the amount of oxygen in the blood. Low oxygen saturation can indicate respiratory distress, which is a common and serious symptom of NAS. Respiratory distress can lead to hypoxia, acidosis, and brain damage. This choice requires immediate follow-up. •

Choice G:

Central nervous system disturbances are common and serious symptoms of NAS. They include tremors, irritability, excessive crying, hyperactivity, increased muscle tone, seizures, and sleep problems. These can indicate severe withdrawal and risk for neurological damage. This choice requires immediate follow-up.

Choice H:

Respiratory rate is a priority finding for a newborn with NAS. The respiratory rate measures the number of breaths per minute. A high respiratory rate can indicate respiratory distress, which is a common and serious symptom of NAS. Respiratory distress can lead to hypoxia, acidosis, and brain damage. This choice requires immediate follow-up.

Choice A reason:

Tremors are not a sign of hyperbilirubinemia, but they may indicate other problems such as hypoglycemia, hypocalcemia, or seizures. Tremors are involuntary muscle movements that can affect different parts of the body.

Choice B reason:

Newborn rash, also known as erythema toxicum, is a common and harmless skin condition that affects many newborns. It causes red spots with white or yellow centers on the face, chest, back, or limbs. It is not related to hyperbilirubinemia or liver function.

Choice C reason:

Cephalohematoma is a collection of blood under the scalp that occurs due to trauma during delivery. It can increase the risk of hyperbilirubinemia because the breakdown of red blood cells in the hematoma releases bilirubin into the bloodstream. Bilirubin is a yellow pigment that is normally processed by the liver and excreted in stool and urine. If the liver is overwhelmed by the amount of bilirubin, it can cause jaundice, which is yellowing of the skin and eyes.

Choice D reason:

Acrocyanosis is a bluish discoloration of the hands and feet that occurs in some newborns due to poor circulation. It is usually a normal and transient phenomenon that does not indicate any serious problem. It is not a sign of hyperbilirubinemia or liver dysfunction.