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
Administering oxygen may help with symptoms like headache and weakness, but it does not address the underlying issue of poor circulation and potential shock. Elevating the legs is more effective in improving blood flow to vital organs.
Choice B rationale
Offering an ice pack is not appropriate for the symptoms described. The client is showing signs of shock, and an ice pack would not address the underlying issue.
Choice C rationale
Providing a warm blanket may offer comfort, but it does not address the symptoms of shock. Elevating the legs is a more direct intervention to improve circulation and stabilize the client.
Choice D rationale
Elevating the client’s legs helps improve venous return to the heart, increasing cardiac output and stabilizing blood pressure. This is a critical intervention for a client showing signs of shock.
Correct Answer is D
Explanation
Choice A rationale
Assessing the client’s socioeconomic status is important but not the primary action the nurse should take in the maternal newborn unit. The focus should be on providing unbiased teachings based on the client’s needs.
Choice B rationale
Collecting a dietary history is important but not the primary action the nurse should take in the maternal newborn unit. The focus should be on providing unbiased teachings based on the client’s needs.
Choice C rationale
Determining the best method of contraception for the client is important but not the primary action the nurse should take in the maternal newborn unit. The focus should be on providing unbiased teachings based on the client’s needs.
Choice D rationale
Performing unbiased teachings based on the client’s needs is the primary action the nurse should take in the maternal newborn unit. This ensures that the client receives accurate and relevant information tailored to their specific situation.