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A nurse is assisting with the care of a newborn who has neonatal abstinence syndrome.Which of the following actions should the nurse take first?

A.

Auscultate the newborn’s bowel sounds.

B.

Swaddle the newborn in blankets.

C.

Weigh the newborn’s wet diaper.

D.

Determine the newborn’s respiratory rate.

Answer and Explanation

The Correct Answer is D

Choice A rationale

 

Auscultating the newborn’s bowel sounds is important for assessing gastrointestinal function, but it is not the first priority in managing a newborn with neonatal abstinence syndrome (NAS). Initial care should focus on stabilizing the newborn and addressing withdrawal symptoms.

 

Choice B rationale

 

Swaddling the newborn in blankets can help provide comfort and reduce excessive stimulation, which is beneficial for newborns with NAS. However, it is not the first priority. The primary focus should be on assessing and stabilizing the newborn’s vital signs.

 

Choice C rationale

 

Weighing the newborn’s wet diaper is important for monitoring fluid balance and hydration status, but it is not the first priority in managing NAS. Initial care should focus on stabilizing the newborn and addressing withdrawal symptoms.

 

Choice D rationale

 

Determining the newborn’s respiratory rate is the first priority in managing a newborn with NAS. Assessing and stabilizing the newborn’s vital signs, including respiratory rate, is crucial to ensure the newborn’s immediate health and safety.


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View Related questions

Correct Answer is B

Explanation

Choice A rationale

A large banana is not a significant source of dietary calcium. While bananas are nutritious and provide potassium and vitamin C, they do not contain enough calcium to meet the needs of a pregnant client who does not consume dairy products.

Choice B rationale

Kale is an excellent non-dairy source of calcium. Dark leafy greens like kale are rich in calcium, with approximately 90 mg of calcium per cup when cooked. Including kale in the diet can help pregnant women meet their calcium needs, especially if they do not consume dairy products.

Choice C rationale

A baked potato is not a significant source of dietary calcium. While potatoes provide several nutrients, including potassium and vitamin C, they do not contain enough calcium to be recommended as a primary source for a pregnant client who does not consume dairy products.

Choice D rationale

White corn is not a significant source of dietary calcium. While it can contribute to overall nutritional intake, it does not provide enough calcium to meet the needs of a pregnant client who does not consume dairy products.

Correct Answer is D

Explanation

Choice A rationale

Providing additional hydration by offering glucose water is not recommended. Breast milk or formula should be the primary source of hydration for newborns.

Choice B rationale

Monitoring the newborn’s heart rate every 2 hours is not necessary for phototherapy. The focus should be on monitoring bilirubin levels, hydration status, and ensuring the newborn’s eyes are protected.

Choice C rationale

Applying a water-based lotion to the newborn’s skin every 4 hours is not recommended. Lotions can interfere with the effectiveness of phototherapy and may cause skin irritation.

Choice D rationale

Removing the newborn from phototherapy every 2 hours for breastfeeding is recommended. Frequent breastfeeding helps to promote bilirubin excretion and maintain hydration.

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