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A nurse is teaching a newly licensed nurse about neonatal abstinence syndrome.
Which of the following statements by the newly licensed nurse indicate understanding of the teaching?

A.

"The newborn will have decreased muscle tone.”.

B.

"The newborn will have a continuous high-pitched cry.”.

C.

"The newborn will sleep for 2 to 3 hours after a feeding.”.

D.

"The newborn will have mild tremors when disturbed.”.

Answer and Explanation

The Correct Answer is B

Choice A rationale

Decreased muscle tone is not typically associated with neonatal abstinence syndrome (NAS). Instead, NAS often presents with hypertonia or increased muscle tone due to

withdrawal symptoms.

 

Choice B rationale

A continuous high-pitched cry is a hallmark sign of NAS, indicating the newborn is experiencing withdrawal and discomfort. This symptom results from the overstimulation of the

central nervous system.

 

Choice C rationale

Newborns with NAS often have difficulty sleeping and may sleep for shorter periods due to irritability and discomfort. Prolonged sleep after feeding is not characteristic of NAS.

 

Choice D rationale

Tremors in newborns with NAS are usually pronounced and continuous, not just when disturbed. These tremors are a result of withdrawal effects on the nervous system.


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View Related questions

Correct Answer is A

Explanation

Choice A rationale

Blood pressure of 160/110 indicates severe preeclampsia and warrants immediate intervention to prevent complications. Stopping oxytocin is part of the management of severe

preeclampsia to avoid exacerbating the condition.

Choice B rationale

Frequency of contractions every 3 minutes is within the normal range during labor induction and does not warrant stopping the infusion unless there are other concerns.

Choice C rationale

A fetal heart rate of 155 bpm with early decelerations may require close monitoring but does not necessarily warrant stopping the oxytocin infusion. Early decelerations are typically a

normal physiological response.

Choice D rationale

Frequency of contractions every 3 minutes is expected during active labor and is generally not a cause to stop the oxytocin infusion. The nurse should continue to monitor the labor

progression closely.

Correct Answer is D

Explanation

Choice A rationale

Numbness in the toes and heel might suggest nerve involvement but is not a typical sign of deep vein thrombosis (DVT), which involves the veins, not nerves.

Choice B rationale

Pain relieved by dorsiflexion (positive Homan's sign) is not reliable for diagnosing DVT. This symptom is outdated and not considered a definitive sign.

Choice C rationale

Spider-like and purple veins suggest superficial varicose veins, not deep vein thrombosis, which affects deeper veins and presents differently.

Choice D rationale

Swelling, redness, and warmth in the calf are classic signs of DVT due to the inflammation and obstruction of deep veins. These symptoms should prompt immediate medical evaluation and intervention. .

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