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The nurse in the newborn nursery is watchful for neonatal abstinence syndrome in the newborn of a mother who took opioids during pregnancyWhat would be the manifestations of this syndrome?
- A. Body tremors
- B. Excessive sneezing
- C. Hyperirritability
- D. Drowsiness
- E. Excessive appetite
Correct Answer: A,B,C
Rationale: Neonatal abstinence syndrome manifests as tremors, hyperirritability, and excessive sneezing due to opioid withdrawal.
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The nurse is obtaining intake information on a new patient being seen for preconception care and notes a family history of neural tube defectsW. hat interventions can the nurse suggest to this woman to help prevent neural tube anomalies in a developing fetus?
- A. Avoid drug use.
- B. Follow a low-calorie, low-protein diet.
- C. Take a folic acid supplement every day.
- D. Exercise daily.
- E. Maintain bed rest during the first trimester.
Correct Answer: A,C
Rationale: Avoiding drug use and taking a daily folic acid supplement (0.4 mg) until the 12th week of pregnancy reduces the risk of neural tube defects.
What nursing action will the nurse implement after feeding an infant with hydrocephalus?
- A. Position the infant sitting upright in an infant seat.
- B. Place the infant over the shoulder to burp.
- C. Leave the infant in a side-lying position.
- D. Stimulate the infant by rubbing its feet.
Correct Answer: C
Rationale: Children with hydrocephalus are prone to vomiting; a side-lying position in a quiet atmosphere after feeding reduces the incidence of vomiting.
What will the nurse include in the plan of care when caring for an infant with an intracranial hemorrhage?
- A. Keep positioned with head elevated.
- B. Feed slowly to reduce possibility of vomiting.
- C. Stimulate often to maintain level of consciousness.
- D. Hold and coddle frequently to stimulate.
- E. Observe for increased intracranial pressure.
Correct Answer: A,B,E
Rationale: Care includes keeping the head elevated, feeding slowly to prevent vomiting, and monitoring for increased intracranial pressure, while avoiding stimulation.
The nurse knows that what is the usual treatment for an infant with this diagnosis?
- A. A Pavlik harness
- B. A body spica cast
- C. Traction
- D. Triple-diapering
Correct Answer: A
Rationale: For infants over 2 months with developmental hip dysplasia, a Pavlik harness is used for longer-term immobilization.
What will the nurse instruct the parents to report immediately?
- A. Facial paralysis
- B. Ear infections
- C. Increased intracranial pressure (ICP)
- D. Drooling
Correct Answer: B
Rationale: Children with cleft palate are at risk for ear infections; parents should report signs of earache immediately to the healthcare provider.