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 A
Explanation
Choice A rationale
This finding indicates fetal distress. Recurrent variable decelerations in the fetal heart rate (FHR) can be a sign of umbilical cord compression, which can compromise fetal oxygenation.
Choice B rationale
Uterine contractions every 6 minutes are within the normal range for the latent phase of labor and do not indicate fetal risk.
Choice C rationale
Moderate variability of the FHR is a reassuring sign and suggests that the fetus is well-oxygenated and neurologically intact.
Choice D rationale
Uterine contractions lasting 30 to 45 seconds are typical for the latent phase of labor and do not indicate fetal distress.
Correct Answer is B
Explanation
Choice A rationale
Disabling the driver-side airbags is not advisable as airbags provide crucial protection in the event of a collision. Proper seating position is a safer alternative.
Choice B rationale
Moving the seat as far away as possible from the steering wheel reduces the risk of injury from airbag deployment and allows ample space for the growing abdomen, providing better safety for both mother and baby.
Choice C rationale
Wearing the lap belt high across the abdomen is incorrect and dangerous as it can cause injury to the fetus. The belt should be low across the hips.
Choice D rationale
Placing the shoulder harness across the gravid uterus is incorrect. The harness should go between the breasts and to the side of the belly, not across it, to avoid compression injuries in the event of a crash.