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
Breastfeeding at least six times per day is too infrequent for a newborn. Newborns typically need to feed more frequently, approximately 8-12 times in 24 hours, to establish a good milk supply and ensure adequate nutrition.
Choice B rationale
Keeping a baby on a strict breastfeeding schedule is not recommended. Feeding should be on demand, based on the baby's hunger cues, to promote effective breastfeeding and milk production.
Choice C rationale
Feeding the baby for 30 minutes during each feeding is correct. This duration allows adequate time for the baby to receive both foremilk and hindmilk, which is essential for nutrition and satiety.
Choice D rationale
Holding the baby just below the level of the breast is incorrect. The baby should be held at breast level to facilitate proper latch and comfortable feeding for both mother and baby. .
Correct Answer is C
Explanation
Choice A rationale
The newborn's legs flexing at the knees and hips when pressure is applied to the soles indicates the stepping reflex, an expected response.
Choice B rationale
Newborns do not typically keep their eyes closed when tapped on the forehead; this is not an expected reflex response.
Choice C rationale
The palmar grasp reflex, where the newborn's fingers curl around the nurse's finger, is an expected and normal finding in newborns, indicating healthy neurological function.
Choice D rationale
The rooting reflex, where the newborn turns their head when their cheek is touched, is expected and demonstrates feeding readiness and normal neural development. .