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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 D

Explanation

Choice A rationale

Instructing the client to apply anesthetic spray to the site three to four times a day is incorrect. While anesthetic sprays can help with pain relief, it's more important to manage swelling and discomfort with a combination of methods, including ice packs and perineal care.

Choice B rationale

Encouraging the client to change perineal pads at least three times a day is insufficient. Pads should be changed more frequently to maintain hygiene and prevent infection.

Choice C rationale

Assisting the client to fill the squeeze bottle with cold water to perform perineal care is incorrect. While perineal care is important, cold water is not typically recommended as it may not provide comfort and might even cause discomfort.

Choice D rationale

Alternating warm and ice packs to the site every 2 hours for the first 24 hours postpartum is correct. This method helps manage pain and swelling effectively, promoting healing and comfort for the client.

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.

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