A baby is grunting in the neonatal nursery.
Which of the following actions by the nurse is appropriate?
Place a pacifier in the baby's mouth.
Check the baby's diaper.
Have the mother feed the baby.
Assess the respiratory rate.
The Correct Answer is D
Choice A rationale
Placing a pacifier in the baby's mouth is inappropriate because it does not address the underlying cause of grunting, which can be a sign of respiratory distress.
Choice B rationale
Checking the baby's diaper is not relevant to assessing the cause of grunting. Grunting is usually related to respiratory issues rather than a dirty diaper.
Choice C rationale
Having the mother feed the baby is inappropriate because grunting may indicate respiratory distress. Feeding should be deferred until the baby's respiratory status is assessed and stabilized.
Choice D rationale
Assessing the respiratory rate is appropriate because grunting in a newborn can indicate respiratory distress. The nurse should evaluate the respiratory status to determine the need for further intervention.
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Correct Answer is B
Explanation
Choice A rationale
Decreased muscle tone is not typically associated with neonatal abstinence syndrome (NAS). Instead, NAS often presents with hypertonia or increased muscle tone due to
withdrawal symptoms.
Choice B rationale
A continuous high-pitched cry is a hallmark sign of NAS, indicating the newborn is experiencing withdrawal and discomfort. This symptom results from the overstimulation of the
central nervous system.
Choice C rationale
Newborns with NAS often have difficulty sleeping and may sleep for shorter periods due to irritability and discomfort. Prolonged sleep after feeding is not characteristic of NAS.
Choice D rationale
Tremors in newborns with NAS are usually pronounced and continuous, not just when disturbed. These tremors are a result of withdrawal effects on the nervous system.
Correct Answer is C
Explanation
Choice A rationale
While maternal lacerations are a risk during childbirth, they are not the greatest risk in cases of fetal dystocia. The focus is primarily on fetal wellbeing.
Choice B rationale
Fetal injury such as bruising can occur with dystocia, but the primary concern is the potential for severe, life-threatening complications.
Choice C rationale
Neonatal asphyxia related to prolonged labor is the greatest risk with fetal dystocia. Prolonged labor can lead to decreased oxygen supply to the fetus, causing asphyxia and
potential brain injury.
Choice D rationale
Increased consideration for a cesarean delivery is a possible outcome of fetal dystocia, but it is a management decision rather than a direct risk to the baby’s immediate health.