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Which of the following symptoms should the nurse recognize as a manifestation of neonatal abstinence syndrome?

A.

Weak cry.

B.

Decreased muscle tone.

C.

Exaggerated Moro reflex.

D.

Consoles easily.

Answer and Explanation

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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View Related questions

Correct Answer is A

Explanation

Choice A rationale

Each feeding should last between 20 and 30 minutes to ensure the baby gets enough nutrition and to facilitate bonding time.

Choice B rationale

Prepared formula should be used within 24 hours if stored in the refrigerator, not 5 days, to prevent bacterial growth and ensure the baby's safety.

Choice C rationale

Formula left at room temperature should not be refrigerated for reuse; it can develop bacteria that may harm the baby.

Choice D rationale

It is recommended to burp the baby multiple times during feeding to release swallowed air and prevent discomfort or spitting up.

Correct Answer is D

Explanation

Choice A rationale

This statement is incorrect because after a cesarean birth, clients are usually started on clear liquids and then gradually progress to regular food as tolerated. Swallowing safety is related to anesthesia recovery, not cesarean birth recovery.

Choice B rationale

This statement is incorrect because the client does not need to stay flat on their back for 24 hours. Early ambulation is encouraged to prevent complications such as deep vein thrombosis and promote recovery.

Choice C rationale

This statement is incorrect because the urinary catheter is typically removed within 24 hours after surgery to reduce the risk of urinary tract infections and encourage normal bladder function.

Choice D rationale

This statement is correct because after a cesarean birth, the nurse will frequently assess the uterus for firmness and massage it as needed to prevent postpartum hemorrhage.

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