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A nurse is assessing a newborn who is 48 hr old and has a maternal history of methadone use during pregnancy. Which of the following manifestations should the nurse identify as an indication of neonatal abstinence syndrome?
- A. Hyporeactivity.
- B. Excessive high-pitched cry.
- C. Acrocyanosis.
- D. Respiratory rate of 50/min.
Correct Answer: B
Rationale: Excessive high-pitched crying results from central nervous system hyperirritability caused by withdrawal. Neonatal abstinence syndrome involves exaggerated responses to stimuli, reflecting the neonate's difficulty in self-regulation.
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A nurse is developing a plan of care for a newborn who has hyperbilirubinemia and a prescription for phototherapy. Which of the following interventions should the nurse include?
- A. Check the newborn's temperature every 8 hours.
- B. Apply moisturizing lotion to the newborn's skin every 4 hours.
- C. Reposition the newborn every 2 to 3 hours.
- D. Give the newborn 1 oz of glucose water every 4 hours.
Correct Answer: C
Rationale: Repositioning every 2-3 hours evenly exposes all skin areas to light, optimizing bilirubin breakdown and preventing pressure ulcers, ensuring effective phototherapy outcomes and skin integrity.
A nurse is caring for a client who is postpartum, has a deep-vein thrombosis, and is receiving heparin therapy via subcutaneous injections. Which of the following actions should the nurse take?
- A. Request a prescription for PRN aspirin from the provider.
- B. Massage the injection site thoroughly following administration.
- C. Instruct the client that they cannot breastfeed while receiving heparin.
- D. Administer the injection in the client's abdomen.
Correct Answer: D
Rationale: The abdomen is the preferred site for subcutaneous heparin injections due to its fatty tissue, which minimizes risks of intramuscular bleeding and ensures consistent drug absorption.
For each of the following potential antihypertensive medications, indicate whether it is recommended or not recommended for use in a pregnant client.
- A. Methyldopa.
- B. Lisinopril.
- C. Labetalol.
- D. Losartan.
- E. Hydralazine.
Correct Answer: A,C,E
Rationale: Methyldopa (A) is safe and effective for pregnancy-induced hypertension. Labetalol (C) is recommended for hypertensive crises with a favorable safety profile. Hydralazine (E) is safe for severe hypertensive emergencies. Lisinopril (B) and Losartan (D) are contraindicated due to teratogenic risks.
A nurse is providing dietary teaching to a client who is at 29 weeks of gestation and has phenylketonuria. Which of the following food suggestions should the nurse include?
- A. Peanut butter sandwich.
- B. Sliced apples.
- C. Glass of skim milk.
- D. Scrambled egg.
Correct Answer: B
Rationale: Apples are low in phenylalanine, making them a safe option for individuals with phenylketonuria. They provide essential nutrients without contributing to phenylalanine accumulation.
Following this type of birth, the nurse should monitor the client for hemorrhage and monitor the newborn for facial nerve palsy. What additional care should the nurse consider?
- A. Administering prophylactic antibiotics to prevent infection.
- B. Assessing for signs of jaundice in the newborn.
- C. Monitoring the client's vital signs for stability.
- D. Educating the client on breastfeeding techniques.
Correct Answer: B
Rationale: Jaundice assessment is critical for newborns with facial bruising or cephalohematoma, as bilirubin levels may rise due to blood breakdown in the localized hematoma.