Which of the following symptoms should the nurse recognize as a manifestation of neonatal abstinence syndrome?
Weak cry.
Decreased muscle tone.
Exaggerated Moro reflex.
Consoles easily.
The Correct Answer is C
Choice A rationale
A weak cry is not a typical manifestation of neonatal abstinence syndrome (NAS). NAS usually presents with a high-pitched, persistent cry due to central nervous system irritability.
Choice B rationale
Decreased muscle tone is not common in NAS. Infants with NAS often exhibit hypertonia, characterized by increased muscle tone and rigidity.
Choice C rationale
This statement is correct because an exaggerated Moro reflex is a common sign of NAS, indicating central nervous system hyperactivity in response to withdrawal from maternal drugs.
Choice D rationale
An infant with NAS does not console easily. They are often difficult to soothe due to irritability and discomfort from withdrawal symptoms. .
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Correct Answer is C
Explanation
Choice A rationale
Taking an over-the-counter antacid is not recommended for managing nausea during pregnancy without consulting a healthcare provider. Some antacids contain ingredients that may not be safe during pregnancy.
Choice B rationale
Increasing intake of fresh fruits might help with hydration and nutrition but is not specifically effective in managing morning nausea. Some fruits might even exacerbate nausea due to their acidity.
Choice C rationale
Eating dry, bland foods in the morning can help manage nausea for pregnant clients. Foods like crackers, toast, and cereals are easy on the stomach and can help reduce morning sickness.
Choice D rationale
Restricting fluids to 1,000 mL/day is not advisable. Proper hydration is crucial during pregnancy, and such restriction can lead to dehydration and other complications. Fluids should be encouraged rather than restricted.
Correct Answer is D
Explanation
Choice A rationale
Remaining in the sitz bath for only 10 minutes might not provide enough relief for a postpartum client with an episiotomy and hemorrhoids. Extended periods in a sitz bath can help reduce pain and promote healing.
Choice B rationale
Using numbing spray before cleansing is helpful for pain management, but it is not as beneficial as other methods for reducing inflammation and promoting healing.
Choice C rationale
Placing a heat pack to the area several times a day can help with pain but might not be as effective as other options in reducing swelling and promoting healing of hemorrhoids and episiotomy sites.
Choice D rationale
Applying witch hazel pads after urination helps reduce swelling, provides soothing relief, and promotes healing for both hemorrhoids and episiotomy sites. Witch hazel has natural astringent properties that are beneficial for postpartum perineal care.