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?
Auscultate the newborn’s bowel sounds.
Swaddle the newborn in blankets.
Weigh the newborn’s wet diaper.
Determine the newborn’s respiratory rate.
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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Correct Answer is D
Explanation
Choice A rationale
Serum bilirubin is not the priority test for hyperemesis gravidarum. It is more relevant for assessing liver function and jaundice.
Choice B rationale
Liver enzymes may be elevated in hyperemesis gravidarum, but they are not the priority test. The primary concern is dehydration and electrolyte imbalance.
Choice C rationale
A CBC can provide information on the client’s overall health, but it is not the priority test for hyperemesis gravidarum. The focus should be on assessing hydration status.
Choice D rationale
Urinalysis for ketones is the priority test because it helps assess the severity of dehydration and malnutrition. The presence of ketones indicates that the body is breaking down fat for energy, which is a sign of inadequate caloric intake.
Correct Answer is D
Explanation
Choice A rationale
Using a breast pump can help maintain milk supply if the client plans to return to work, but it does not directly prevent mastitis.
Choice B rationale
Covering the breasts immediately after feedings is not necessary and does not prevent mastitis. Proper hygiene and feeding techniques are more important.
Choice C rationale
Wearing an underwire bra can restrict milk flow and increase the risk of mastitis. A well-fitting, non-restrictive bra is recommended.
Choice D rationale
Washing nipples with soap and water daily can cause dryness and irritation, increasing the risk of mastitis. It is better to clean the nipples with water only and ensure proper latch and feeding techniques. .