A pregnant client with a history of heroin use is admitted to the birthing unit. The client is currently in a treatment program and has been on stable doses of methadone during her pregnancy. She tells the nurse, “I know my baby may go through withdrawal after delivery. What will happen?” The nurse correctly tells her that her baby may: (Select all that apply)

Sleep deeply.

Have a high-pitched cry.

Not feed well.

Have some shaking.

Sweat a lot.

Answer and Explanation

Correct Answer : B,C,D,E

Choice A rationale

Deep sleep is not a characteristic of neonatal abstinence syndrome; rather, infants tend to exhibit irritability and disturbed sleep patterns due to central nervous system hyperirritability caused by opioid withdrawal.

Choice B rationale

A high-pitched cry occurs due to central nervous system overstimulation and hyperirritability, which are hallmark features of neonatal abstinence syndrome and a direct result of opioid withdrawal in neonates.

Choice C rationale

Poor feeding is common in neonatal abstinence syndrome due to uncoordinated suck reflexes and gastrointestinal disturbances, leading to difficulty maintaining adequate nutrition and hydration in affected neonates.

Choice D rationale

Neonates with neonatal abstinence syndrome often exhibit tremors or shaking as a result of central nervous system hyperirritability, which is a hallmark symptom of opioid withdrawal in newborns.

Choice E rationale

Excessive sweating is a manifestation of autonomic nervous system dysregulation caused by opioid withdrawal in neonates, commonly observed in infants with neonatal abstinence syndrome.

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Correct Answer is A

Explanation

Choice A rationale

Tone refers to uterine atony, the leading cause of postpartum hemorrhage. Tissue refers to retained placental fragments. Trauma includes lacerations or uterine rupture. Thrombin relates to coagulation disorders impacting clotting.

Choice B rationale

TOLAC (Trial of Labor After Cesarean) and thrombosis are unrelated to immediate hemorrhage management. Thrombosis generally involves venous clots, differing from thrombin, which concerns clotting factor deficiencies causing bleeding.

Choice C rationale

Tear and tolerance are non-specific terms lacking relevance to postpartum hemorrhage management. Time to search is impractical and unrelated to immediate intervention for hemorrhage or its causes.

Choice D rationale

"None of the above" is incorrect as the Four Ts (Tone, Tissue, Trauma, Thrombin) specifically address the primary causes of postpartum hemorrhage and are universally accepted in clinical guidelines.

A. Harm to herself or her infant. B. Displaying outbursts of anger. C. Neglecting her hygiene. D. Losing trust in her husband.

Correct Answer is A

Explanation

Choice A rationale

Postpartum depression with psychotic features may lead to suicidal ideation or infanticidal tendencies due to delusions or hallucinations. Ensuring safety is critical to prevent harm to both mother and infant.

Choice B rationale

Anger outbursts, though concerning, do not pose immediate threats like harm to self or infant. Addressing this behavior is secondary to prioritizing safety in severe postpartum psychosis cases.

Choice C rationale

Neglecting hygiene reflects depressive symptoms but does not indicate psychosis severity or imminent danger. Primary focus remains on managing safety risks to the mother and infant.

Choice D rationale

Losing trust in her husband is relevant to interpersonal stress but does not constitute a primary care concern. The immediate threat of harm takes precedence over marital dynamics.

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Naxlex Comprehensive Predictor Exams

What are the four Ts as they relate to postpartum hemorrhage?

Correct Answer is A

Explanation

When a woman is diagnosed with postpartum depression (PPD) with psychotic features, what is the nurse’s primary concern in planning the client’s care?

Correct Answer is A

Explanation

Medications used to manage postpartum hemorrhage (PPH) include: (Select all that apply)

One possibly fatal complication of prolonged postpartum hemorrhage is:

A macrosomic infant is born after a difficult delivery. After stabilization, the infant is weighed, and the birth weight is 4550 g (9 pounds, 6 ounces). The nurse’s most appropriate action is to:

A baby is born with a diaphragmatic hernia. Which of the following signs/symptoms would the nurse likely observe in the delivery room?

One of the greatest mediators of risks to an infant with a myelomeningocele is:

A premature infant with respiratory distress syndrome receives artificial surfactant. How would the nurse explain surfactant therapy to the parents?

The perinatal nurse is caring for a woman in the immediate postbirth period. Assessment reveals that the woman is experiencing profuse bleeding. The most likely etiology for the bleeding is:

The nurse is making a home visit three weeks postpartum. The nurse suspects the client is experiencing postpartum depression when she makes which of the following statements?