Which nursing interventions are appropriate while caring for a newborn whose mother was addicted to heroin during the pregnancy? (Select All that Apply.)

Offer the newborn a pacifier

Observe the newborn in a well-lit nursery

Maintain low stimulation environment

Administer oral glucose for comfort

Swaddle newborn tightly

Feed the infant half strength formula

Answer and Explanation

Correct Answer : A,C,E

A. Offer the newborn a pacifier. This can help soothe the newborn and provide comfort, as infants exposed to opioids in utero often exhibit increased need for sucking.
B. Observe the newborn in a well-lit nursery. This is not appropriate as bright lights can overstimulate and distress the newborn.
C. Maintain a low stimulation environment. This helps reduce stress and irritability in newborns undergoing withdrawal, who can be hypersensitive to stimuli.
D. Administer oral glucose for comfort. Glucose is not typically used for comfort in NAS management; comforting measures like swaddling and pacifiers are preferred.
E. Swaddle the newborn tightly. Tight swaddling can provide a sense of security and help manage symptoms of neonatal abstinence syndrome (NAS) by reducing irritability and promoting sleep.
F. Feed the infant half-strength formula. Infants with NAS usually require regular, full-strength formula to meet nutritional needs unless otherwise indicated by specific feeding issues.

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Correct Answer is ["A","C","E"]

Explanation

A. Rhythmic suckling. Indicates the infant is effectively extracting milk.
B. A slurping sound as the infant sucks. This suggests poor latch and possible ingestion of air.
C. Tongue down with lips flanged. Shows that the infant's tongue is extended over the lower gum and lips are flared outward, creating a seal.
D. Dimpling of the infant's cheeks while sucking. Indicates improper latch and poor seal around the breast.
E. Audible swallowing. Indicates milk transfer is occurring as the infant swallows.

A. Ensuring that the client takes care of their ADLS to prevent dependence. B. Ensuring that the client environment is safe to prevent injury. C. Ensuring that the client receives food they like to prevent anxiety. D. Ensuring that the client meets the other patients to prevent social isolation.

Correct Answer is B

Explanation

A. Ensuring that the client takes care of their ADLS to prevent dependence: While promoting independence is important, ensuring safety is a higher priority to prevent immediate harm.
B. Ensuring that the client environment is safe to prevent injury: Safety is the top priority for clients with Alzheimer's due to their increased risk of falls, wandering, and other accidents. A safe environment helps prevent injuries.
C. Ensuring that the client receives food they like to prevent anxiety: Although providing familiar and preferred foods can reduce anxiety, it is not as critical as ensuring a safe environment.
D. Ensuring that the client meets the other patients to prevent social isolation: Social interaction is beneficial, but ensuring safety takes precedence to prevent potential harm.

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Which nursing interventions are appropriate while caring for a newborn whose mother was addicted to heroin during the pregnancy? (Select All that Apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is B

Explanation

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