The newborn of a patient suspected to have used drugs during the prenatal period is admitted to the nursery.The nurse caring for the newborn notes that the infant is beginning to exhibit signs of drug withdrawal.Which action should the nurse take?

The correct answer is choice A. Maintaining the infants’ airways is the nurse’s priority when caring for a set of twins delivered by cesarean delivery.This is because twins are more likely to be born early and need special care after birth than single babies.They may have breathing difficulties or low oxygen levels and require oxygen therapy or ventilation.

The nurse should assess the infants’ respiratory status and intervene as needed.

Choice B is wrong because keeping the infants in a warm, draft-free environment is important but not as urgent as ensuring their airways are clear and they are breathing well.Premature twins may have trouble regulating their body temperature and need to be kept warm, but this can be done after their airways are secured.

Choice C is wrong because placing identification bands on the infants is a standard procedure but not a priority.

The nurse should make sure the infants are correctly identified and matched with their mother, but this can be done after their vital signs are stable.

Choice D is wrong because monitoring the infants’ vital signs is also important but not as urgent as maintaining their airways.

The nurse should check the infants’ heart rate, blood pressure, temperature and blood sugar levels regularly, but this can be done after their respiratory status is assessed and managed.

Normal ranges for vital signs in newborns are:

• Heart rate: 100 to 160 beats per minute

• Blood pressure: 50 to 75 mm Hg systolic and 30 to 45 mm Hg diastolic

• Temperature: 36.5 to 37.5°C (97.7 to 99.5°F)

• Blood sugar: 40 to 80 mg/dL

The correct answer is choice D. It will be necessary for a Cesarean section when labor begins.This is because a pregnant person with herpes simplex virus (HSV) type II can pass the infection to the baby during childbirth, which can be life-threatening.A Cesarean section can lower the risk of infection by avoiding contact with the virus in the genital area.

Choice A is wrong because herpes can recur after delivery, especially if the person has a history of genital herpes before pregnancy.Choice B is wrong because weekly cultures of the herpes site are not recommended during pregnancy, as they are not reliable indicators of viral shedding or risk of transmission.Choice C is wrong because it is possible to have more than one herpes outbreak during pregnancy, especially if the person has a primary or nonprimary first-episode infection in the third trimester.