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 D
Explanation
Choice A rationale
Bumper pads can pose a suffocation risk to the newborn. The American Academy of Pediatrics advises against their use to promote a safe sleep environment.
Choice B rationale
Foam-wedge cushions are not recommended as they can increase the risk of suffocation and Sudden Infant Death Syndrome (SIDS) by obstructing airflow.
Choice C rationale
Plastic covers can pose a suffocation hazard. Instead, using a fitted sheet is safer and reduces the risk of suffocation.
Choice D rationale
A well-fitting mattress reduces gaps between the mattress and crib sides, preventing entrapment, which helps reduce the risk of suffocation and injury.
Correct Answer is B
Explanation
Choice A rationale
Ensuring the client has a full bladder before the procedure is incorrect. A full bladder can cause discomfort during the pelvic examination and may obscure the pelvic organs, making the examination more challenging for the provider.
Choice B rationale
Instructing the client to bear down when the speculum is inserted is correct. Bearing down helps relax the pelvic muscles, making it easier to insert the speculum and perform the examination with minimal discomfort.
Choice C rationale
Encouraging the client to take rapid, shallow breaths during the procedure is incorrect. This can increase anxiety and tension in the pelvic muscles, making the examination more uncomfortable.
Choice D rationale
Applying povidone-iodine to the provider's fingers prior to bimanual examination is incorrect. The standard procedure involves using gloves and lubricant to prevent infection and ensure patient comfort, not povidone-iodine.