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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 B

Explanation

Choice A rationale

Elevating the client's legs is incorrect as an initial intervention. It is more important to address the potential cause of the late decelerations first.

Choice B rationale

Turning the client onto their side is correct. This intervention can improve blood flow to the fetus and reduce the pressure on the vena cava, potentially alleviating late decelerations.

Choice C rationale

Palpating the client's uterus is not the first action. It is essential to address maternal positioning and oxygenation issues first.

Choice D rationale

Increasing the client's IV fluid infusion rate may help, but it is not the initial action. Positioning changes can have an immediate effect on fetal oxygenation.

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.

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