Which of the following symptoms should the nurse recognize as a manifestation of neonatal abstinence syndrome?
Decreased muscle tone
Exaggerated Moro reflex
Consoles easily
Weak cry
The Correct Answer is B
A. Decreased muscle tone is not typically associated with neonatal abstinence syndrome.
B. Exaggerated Moro reflex, which is a startle response that causes the baby to fling their arms and legs out and then curl them in, is a common signof neonatal abstinence
C. Consoling easily is not a characteristic feature of neonatal abstinence syndrome; these infants are often difficult to console.
D. A high pitched cry is a common symptom of neonatal abstinence syndrome. A weak cry is not anticipated.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Hyporeflexia is a significant adverse effect of magnesium sulfate therapy and can indicate magnesium toxicity. It is essential for the nurse to monitor deep tendon reflexes as part of the assessment when a client is receiving this medication. A decrease in reflexes may warrant immediate intervention and reporting to the provider.
B. Tachypnea is not a common adverse effect of magnesium sulfate; however, if it occurs, it may indicate respiratory distress, which should be assessed further.
C. Polyuria is not a typical adverse effect of magnesium sulfate. In fact, magnesium can lead to decreased urine output in some cases, especially with toxicity.
D. Agitation is also not a typical adverse effect of magnesium sulfate. Clients receiving magnesium sulfate may exhibit sedation rather than agitation.
Correct Answer is B
Explanation
A. There is no fasting requirement for a nonstress test.
B. The client will press a button whenever they feel the baby move during the test to help correlate fetal movement with changes in the fetal heart rate.
C. A nonstress test is not meant to stimulate contractions. It monitors the fetal heart rate in response to the baby's movements.
D. While the client will be monitored, they are not required to lie flat on their back for the entire duration of the test. They may be in a semi-reclining or comfortable position.
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