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A nurse is assessing a newborn who is 48 hours 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: Neonatal abstinence syndrome (NAS) occurs in newborns who were exposed to substances, such as methadone, while in the womb. Infants with NAS may exhibit excessive high-pitched crying as one of the manifestations. Other common symptoms of NAS include irritability, tremors, feeding difficulties, sweating, fever, vomiting, diarrhea, and poor weight gain. Therefore, in this case, the excessive high-pitched cry is a manifestation that the nurse should identify as an indication of neonatal abstinence syndrome.
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The nurse is teaching a prenatal class about labor. What statement indicates understanding?
- A. True labor contractions are irregular and stop with rest.
- B. False labor contractions cause cervical dilation.
- C. True labor contractions increase in intensity and frequency.
- D. False labor contractions are felt in the back.
Correct Answer: C
Rationale: True labor contractions become progressively stronger and lead to cervical dilation and effacement.
What teaching is most important for a mother with a newborn receiving phototherapy?
- A. Ensure the newborn wears protective eyewear
- B. Increase the newborn's fluid intake
- C. Turn the newborn frequently to prevent pressure sores
- D. Monitor bilirubin levels every 8 hours
Correct Answer: A
Rationale: Protective eyewear prevents retinal damage during phototherapy.
Be- tions before finding one that works.
- A. Once you take the prescribed medication, you plan on teaching this client? will be cured of the infection.
- B. Breastfeeding
- C. Even though you don't experience symptoms,
- D. Postpartum depression you can still spread the infection.
Correct Answer: C
Rationale: Option C is the most appropriate statement to make to the client because it addresses the reality of sexually transmitted infections (STIs). Many STIs can be transmitted even when the infected individual is not experiencing any symptoms. This is an important point to communicate to prevent the spread of the infection to other sexual partners. It emphasizes the need for practicing safe sex measures and getting tested regularly, regardless of the presence of symptoms. It is important for the client to understand that they can still be a carrier of the infection even if they are not displaying any noticeable symptoms.
As a nurse working in a prenatal clinic. It is important to obtain maternal and fetal assessing. While obtaining fetal assessments. Which of the following should the complete for fetal well-being?
- A. Fetal movement, maternal vital signs, maternal weight
- B. Fetal movement, fetal position, fetal weight
- C. Fetal position, fetal heart tone, maternal weight
- D. Fetal heart tones, fetal movement, fundal height
Correct Answer: D
Rationale: When assessing fetal well-being in a prenatal clinic, it is important to focus on factors directly related to the fetus. Fetal heart tones provide crucial information about the baby's heart rate and rhythm, indicating how well the fetus is doing. Fetal movement is another essential indicator of fetal well-being, as it shows signs of good neurological function and reactivity. Finally, measuring fundal height (the distance from the top of the uterus to the pubic bone) helps assess fetal growth and development. These three aspects - fetal heart tones, fetal movement, and fundal height - provide a comprehensive evaluation of the baby's well-being and development during pregnancy.
A client at 36 weeks' gestation reports decreased fetal movement. What is the nurse's priority action?
- A. Perform a nonstress test.
- B. Encourage the client to drink orange juice.
- C. Schedule an ultrasound.
- D. Notify the healthcare provider.
Correct Answer: A
Rationale: A nonstress test evaluates fetal well-being and is the first step in assessing decreased fetal movement.