Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
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.
Hyporeactivity is not typically associated with neonatal abstinence syndrome (NAS) NAS is characterized by increased irritability and signs of withdrawal, which are opposite to a hypo- reactive state.
B. Excessive high-pitched cry.
An excessive high-pitched cry is a hallmark sign of neonatal abstinence syndrome. Babies exposed to drugs like methadone during pregnancy can experience withdrawal symptoms, including a distinct high-pitched cry.
C. Acrocyanosis.
Acrocyanosis, a bluish discoloration of the extremities, is a common finding in newborns and is not specific to NAS. It is caused by immature peripheral circulation and usually resolves on its own.
D. Respiratory rate of 50/min.
A respiratory rate of 50/min is within the normal range for a newborn and is not a sign of neonatal abstinence syndrome. NAS symptoms are related to drug withdrawal and not respiratory issues.
This question is an excerpt from Nurse Dive's nursing test bank - ATI Maternal Newborn Proctored Exam. Take the full exam now
Full Explanation
Choice A rationale:
Hyporeactivity is not typically associated with neonatal abstinence syndrome (NAS) NAS is characterized by increased irritability and signs of withdrawal, which are opposite to a hypo- reactive state.
Choice B rationale:
An excessive high-pitched cry is a hallmark sign of neonatal abstinence syndrome. Babies exposed to drugs like methadone during pregnancy can experience withdrawal symptoms, including a distinct high-pitched cry.
Choice C rationale:
Acrocyanosis, a bluish discoloration of the extremities, is a common finding in newborns and is not specific to NAS. It is caused by immature peripheral circulation and usually resolves on its own.
Choice D rationale:
A respiratory rate of 50/min is within the normal range for a newborn and is not a sign of neonatal abstinence syndrome. NAS symptoms are related to drug withdrawal and not respiratory issues.
Similar Questions
A nurse is admitting a client who is at 35 weeks of gestation and is experiencing mild vaginal bleeding due to placenta previa. Which of the following actions should the nurse plan to take?
A. Initiate continuous monitoring of the FHR.
Initiate continuous monitoring of the FHR. For a client with placenta previa, continuous fetal heart rate (FHR) monitoring is essential to assess the baby's well-being due to the risk of fetal distress from reduced oxygen supply. Continuous FHR monitoring is a standard care practice for clients with placenta previa to promptly detect any signs of fetal distress and intervene as necessary.
B. Administer a dose of betamethasone.
Betamethasone is typically administered to enhance fetal lung maturity before 34 weeks of gestation, not for placenta previa. Its use at 35 weeks is less common unless there's a risk of preterm birth within 7 days and the patient hasn't received a previous course.
C. Check the cervix for dilation every 8 hours.
Checking the cervix can induce bleeding and is contraindicated in placenta previa because it may disturb the placental site and exacerbate bleeding.
D. Request that the provider prescribe misoprostol PRN.
Misoprostol is used for labor induction or to treat postpartum hemorrhage. It is not indicated for placenta previa management and can cause uterine contractions leading to increased bleeding.
Full Explanation
The correct answer is A. Initiate continuous monitoring of the FHR. For a client with placenta previa, continuous fetal heart rate (FHR) monitoring is essential to assess the baby's well-being due to the risk of fetal distress from reduced oxygen supply
Choice A reason:
Continuous FHR monitoring is a standard care practice for clients with placenta previa to promptly detect any signs of fetal distress and intervene as necessary.
Choice B reason:
Betamethasone is typically administered to enhance fetal lung maturity before 34 weeks of gestation, not for placenta previa. Its use at 35 weeks is less common unless there's a risk of preterm birth within 7 days and the patient hasn't received a previous course.
Choice C reason:
Checking the cervix can induce bleeding and is contraindicated in placenta previa because it may disturb the placental site and exacerbate bleeding.
Choice D reason:
Misoprostol is used for labor induction or to treat postpartum hemorrhage. It is not indicated for placenta previa management and can cause uterine contractions leading to increased bleeding.
A nurse is reviewing a laboratory report for a client who is at 33 weeks of gestation and has preeclampsia. Which of the following laboratory results should the nurse report to the provider?
A. BUN 35 mg/dL.
The nurse should report a blood urea nitrogen (BUN) level of 35 mg/dL to the provider. BUN measures the amount of nitrogen in the blood and is used to assess kidney function. An elevated BUN can indicate impaired renal function, which is a concern in preeclampsia, as it may signify reduced blood flow to the kidneys.
B. Hgb 15 mg/dL.
Hemoglobin (Hgb) level of 15 mg/dL is within the normal range for pregnancy (normal range: 11-15 g/dL), so there is no need to report it to the provider.
C. Bilirubin 0.6 mg/dL.
Bilirubin level of 0.6 mg/dL is within the normal range (normal range: 0.2-1.3 mg/dL), so there is no need to report it to the provider.
D. Hct 37%.
Hematocrit (Hct) level of 37% is within the normal range for pregnancy (normal range: 33- 45%), so there is no need to report it to the provider.
Full Explanation
Choice A rationale:
The nurse should report a blood urea nitrogen (BUN) level of 35 mg/dL to the provider. BUN measures the amount of nitrogen in the blood and is used to assess kidney function. An elevated BUN can indicate impaired renal function, which is a concern in preeclampsia, as it may signify reduced blood flow to the kidneys.
Choice B rationale:
Hemoglobin (Hgb) level of 15 mg/dL is within the normal range for pregnancy (normal range: 11-15 g/dL), so there is no need to report it to the provider.
Choice C rationale:
Bilirubin level of 0.6 mg/dL is within the normal range (normal range: 0.2-1.3 mg/dL), so there is no need to report it to the provider.
Choice D rationale:
Hematocrit (Hct) level of 37% is within the normal range for pregnancy (normal range: 33- 45%), so there is no need to report it to the provider.
A nurse is assessing a newborn who is 48 hours old and is experiencing opioid withdrawals. Which of the following findings should the nurse expect?
A. Hypotonicity.
Hypotonicity, or decreased muscle tone, is not an expected finding in a newborn experiencing opioid withdrawals. Opioid withdrawal symptoms usually involve increased muscle tone and jitteriness.
B. Moderate tremors of the extremities.
Moderate tremors of the extremities are an expected finding in a newborn experiencing opioid withdrawals. Neonates born to mothers who used opioids during pregnancy can exhibit tremors, irritability, and other withdrawal symptoms.
C. Axillary temperature 36.1°C (96.9°F)
An axillary temperature of 36.1°C (96.9°F) is within the normal range for a newborn's body temperature, so it is not directly related to opioid withdrawal and is not the expected finding in this situation.
D. Excessive sleeping.
Excessive sleeping is not an expected finding in a newborn experiencing opioid withdrawals. Opioid withdrawal can lead to increased wakefulness and irritability in newborns.
Full Explanation
Choice A rationale:
Hypotonicity, or decreased muscle tone, is not an expected finding in a newborn experiencing opioid withdrawals. Opioid withdrawal symptoms usually involve increased muscle tone and jitteriness.
Choice B rationale:
Moderate tremors of the extremities are an expected finding in a newborn experiencing opioid withdrawals. Neonates born to mothers who used opioids during pregnancy can exhibit tremors, irritability, and other withdrawal symptoms.
Choice C rationale:
An axillary temperature of 36.1°C (96.9°F) is within the normal range for a newborn's body temperature, so it is not directly related to opioid withdrawal and is not the expected finding in this situation.
Choice D rationale:
Excessive sleeping is not an expected finding in a newborn experiencing opioid withdrawals. Opioid withdrawal can lead to increased wakefulness and irritability in newborns.