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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 D

Explanation

Choice A rationale

Applying a corticosteroid cream is not appropriate for acute perineal pain. It is more suitable for chronic inflammation or skin conditions.

Choice B rationale

Increasing fluid intake is beneficial for overall health, but it does not directly address acute perineal pain.

Choice C rationale

Catheterizing the bladder is not indicated for perineal pain unless there is a specific issue with urinary retention.

Choice D rationale

Offering an ice pack helps reduce swelling and numb the area, providing immediate relief for acute perineal pain. It is a standard intervention for postpartum perineal discomfort.

Correct Answer is D

Explanation

Choice A rationale

Purchasing furniture for the baby’s room is a common and healthy behavior during pregnancy. It indicates that the client is preparing for the baby’s arrival and is excited about the new addition to the family. This behavior is generally seen as positive and supportive of the pregnancy.

Choice B rationale

Being unsure about wanting an epidural during labor is a normal concern for many pregnant individuals. It reflects the client’s consideration of pain management options and their desire to make an informed decision. This is not typically seen as a psychosocial concern.

Choice C rationale

The partner planning to attend birthing classes with the client is a positive sign of support and involvement in the pregnancy. It indicates that the partner is engaged and willing to participate in the childbirth process, which can be beneficial for the client’s emotional well-being.

Choice D rationale

Expressing uncertainty about whether an older child will accept the new baby can indicate underlying anxiety or stress about family dynamics and the impact of the new baby on existing relationships. This concern may require further exploration and support to ensure the client’s emotional health.

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