A nurse is caring for a newborn who is 72 hr old.
Physical Examination
1100:
Neonatal Abstinence Scoring System (NAS)
Excessive high-pitched cry-2 Sleeps <2 hr 2
Hyperactive Moro reflex=2 Moderate-severe tremors disturbed=2 Increased muscle tone=2
Fever <37.2 to 38.2° C (99 to 100.8° F)=1
Excessive sucking=1 Frequent sneezing=1
Frequent yawning-1 Loose stools=2 Poor feeding=2
Respiratory rate > 60/min=1 Mottling-1
NAS score 20
The nurse is planning to contact the provider regarding the newborn's status. Which of the following prescriptions should the nurse anticipate? Select the 3 interventions the nurse should anticipate.
Swaddle the newborn.
Administer naloxone for NAS scores greater than 24.
Continue NAS scoring as prescribed.
Encourage the birthing parent to breastfeed.
Administer oral morphine.
Correct Answer : A,C,D,E
A.Swaddling can provide comfort to the newborn and may help reduce symptoms of NAS such as tremors and increased muscle tone.
B. Naloxone is not routinely used in the management of neonatal abstinence syndrome (NAS). Naloxone is an opioid antagonist and is not recommended for the treatment of NAS due to the risk of precipitating acute withdrawal in the newborn, which can be life-threatening.
C. Continuing NAS scoring as prescribed is an appropriate intervention. It helps assess the severity of withdrawal symptoms and guides the management plan.
D. Breastfeeding is often encouraged in newborns with NAS as it provides comfort, nutrition, and promotes bonding between the newborn and the birthing parent.
E. Administering oral morphine is one of the pharmacological treatments commonly used for moderate to severe cases of NAS. It helps to alleviate withdrawal symptoms in the newborn and is often titrated based on the severity of symptoms and NAS scoring.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. The client is experiencing postpartum depression. A prescription of antidepressants is important but should come after fully assessing the client's mental state
B. Asking the client if she has considered harming her newborn is important in further assessments to establish the mothers as it is a common feature of postpartum depression.
C. While reinforcing education on postpartum and newborn care is important for overall maternal and infant well-being, it may not directly address the client's current mental health concerns.
D. Exploring options on how to help the client is key but this should comer after a thorough examination has occurred.
Correct Answer is B
Explanation
True labor is characterized by characteristic lower abdominal pain that in frequency and intensity and radiate to the back with progressive changes in the cervix, including effacement and dilation. A, C and D are not reliable features of true labor.
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