Take full exam for free

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.


View Related questions

Correct Answer is ["F","G","H"]

Explanation

Choice A rationale:

Deep tendon reflexes of 1+ are considered normal and do not indicate any immediate concern. Reflexes are graded on a scale from 0 to 4+, with 2+ being normal. A 1+ reflex is slightly diminished but can be normal in some individuals.

Choice B rationale:

A pain rating of 3 on a scale of 0 to 10 is relatively low and manageable. Postpartum pain is expected, and a rating of 3 does not indicate severe pain that requires immediate intervention.

Choice C rationale:

The blood pressure reading of 136/86 mm Hg is slightly elevated but not alarming. Postpartum blood pressure can fluctuate, and this reading does not indicate a hypertensive crisis.

Choice D rationale:

Peripheral edema of 2+ in the bilateral lower extremities is common postpartum due to fluid retention and is not typically a cause for immediate concern unless accompanied by other symptoms such as severe pain or redness.

Choice E rationale:

Soft breasts with intact nipples are normal findings in the early postpartum period, especially if the client is breastfeeding. There is no indication of issues such as mastitis or engorgement.

Choice F rationale:

A large amount of lochia rubra is concerning as it may indicate postpartum hemorrhage. Lochia should gradually decrease in amount and change in color over time. A large amount of bright red blood suggests excessive bleeding that requires immediate follow-up.

Choice G rationale:

A soft uterine tone is abnormal and can indicate uterine atony, which is a leading cause of postpartum hemorrhage. The uterus should be firm and contracted to prevent excessive bleeding.

Choice H rationale:

Lateral deviation of the uterus can indicate a full bladder, which can prevent the uterus from contracting properly and lead to increased bleeding. This requires immediate attention to ensure the bladder is emptied and the uterus can contract effectively.

Correct Answer is B

Explanation

Choice A rationale

Acrocyanosis is a common finding in newborns and is not a sign of dehydration. It usually resolves on its own.

Choice B rationale

A capillary refill time greater than 3 seconds can indicate dehydration in a newborn. It suggests poor perfusion and fluid status.

Choice C rationale

Voiding four times in the past 24 hours is within the normal range for a newborn and does not indicate dehydration.

Choice D rationale

A flat soft anterior fontanel is normal in newborns and does not indicate dehydration. A sunken fontanel would be a sign of dehydration.