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NurseDive Free Nursing Practice Question
A nurse is assisting in the care of a newborn who is 72 hours old and is receiving treatment for neonatal abstinence syndrome.
Which of the following data collection findings should the nurse identify as requiring immediate follow-up? (Select all that apply.).
A. Blood pressure.
Blood pressure is not a priority finding for a newborn with neonatal abstinence syndrome (NAS). Blood pressure may be slightly elevated or normal in NAS, but it is not a sign of severe withdrawal or risk for complications. •
B. Gastrointestinal disturbances.
Gastrointestinal intestinal disturbances are common and serious symptoms of NAS. They include poor feeding, vomiting, diarrhea, dehydration, and poor weight gain. These can lead to electrolyte imbalance, malnutrition, and failure to thrive. This choice requires immediate follow-up.
C. Skin color.
Skincolor is not a priority finding for a newborn with NAS. Skin color may be normal or slightly pale in NAS, but it is not a sign of severe withdrawal or risk for complications.
D. NAS score.
NAS score is a priority finding for a newborn with NAS. NAS score is a tool used to assess the severity of withdrawal symptoms and the need for pharmacological treatment. A high NAS score indicates that the newborn needs medication to manage the withdrawal and prevent complications such as seizures. This choice requires immediate follow-up.
E. Temperature.
Autonomic nervous system instability is a hallmark of NAS. Hyperthermia can lead to metabolic distress.
F. Oxygen saturation.
Oxygen saturation is a priority finding for a newborn with NAS. Oxygen saturation measures the amount of oxygen in the blood. Low oxygen saturation can indicate respiratory distress, which is a common and serious symptom of NAS. Respiratory distress can lead to hypoxia, acidosis, and brain damage. This choice requires immediate follow-up.
G. Central nervous system disturbances.
Central nervous system disturbances are common and serious symptoms of NAS. They include tremors, irritability, excessive crying, hyperactivity, increased muscle tone, seizures, and sleep problems. These can indicate severe withdrawal and risk for neurological damage. This choice requires immediate follow-up.
H. Respiratory rate
Respiratory rate is a priority finding for a newborn with NAS. The respiratory rate measures the number of breaths per minute. A high respiratory rate can indicate respiratory distress, which is a common and serious symptom of NAS. Respiratory distress can lead to hypoxia, acidosis, and brain damage. This choice requires immediate follow-up.
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Full Explanation
Choice A:
Blood pressure is not a priority finding for a newborn with neonatal abstinence syndrome (NAS). Blood pressure may be slightly elevated or normal in NAS, but it is not a sign of severe withdrawal or a risk for complications. •
Choice B:
Gastrointestinal disturbances are common and serious symptoms of NAS. They include poor feeding, vomiting, diarrhea, dehydration and poor weight gain. These can lead to electrolyte imbalance, malnutrition and failure to thrive. This choice requires immediate follow-up. •
Choice C:
Skin color is not a priority finding for a newborn with NAS. Skin color may be normal or slightly pale in NAS, but it is not a sign of severe withdrawal or risk for complications. •
Choice D:
NAS score is a priority finding for a newborn with NAS. NAS score is a tool used to assess the severity of withdrawal symptoms and the need for pharmacological treatment. A high NAS score indicates that the newborn needs medication to manage the withdrawal and prevent complications such as seizures. This choice requires immediate follow-up. •
Choice E:
Autonomic nervous system instability is a hallmark of NAS. Hyperthermia (elevated temperature) can lead to metabolic distress.
Choice F:
Oxygen saturation is a priority finding for a newborn with NAS. Oxygen saturation measures the amount of oxygen in the blood. Low oxygen saturation can indicate respiratory distress, which is a common and serious symptom of NAS. Respiratory distress can lead to hypoxia, acidosis, and brain damage. This choice requires immediate follow-up. •
Choice G:
Central nervous system disturbances are common and serious symptoms of NAS. They include tremors, irritability, excessive crying, hyperactivity, increased muscle tone, seizures, and sleep problems. These can indicate severe withdrawal and risk for neurological damage. This choice requires immediate follow-up.
Choice H:
Respiratory rate is a priority finding for a newborn with NAS. The respiratory rate measures the number of breaths per minute. A high respiratory rate can indicate respiratory distress, which is a common and serious symptom of NAS. Respiratory distress can lead to hypoxia, acidosis, and brain damage. This choice requires immediate follow-up.
Similar Questions
A nurse is assisting in the care of a newborn who is 72 hours old and is receiving treatment for neonatal abstinence syndrome.
Which of the following data collection findings should the nurse identify as requiring immediate follow-up? (Select all that apply.).
A. Blood pressure.
The normal blood pressure range for a newborn is 60 to 80 mm Hg systolic and 40 to 50 mm Hg diastolic. The baby's blood pressure is low, which could indicate shock, dehydration, infection, or heart failure. This requires immediate follow-up to identify and treat the cause.
B. Gastrointestinal disturbances.
Gastrointestinal disturbances such as vomiting and diarrhea are common symptoms of neonatal abstinence syndrome (NAS), which is a withdrawal syndrome of infants after birth caused by in-utero exposure to drugs of dependence, most commonly opioids. These symptoms are not life-threatening and can be managed with supportive care such as hydration, nutrition, and comfort measures.
C. Skin color.
Skin color is not a reliable indicator of NAS, as it can vary depending on the baby's ethnicity, temperature, oxygenation and circulation. Skin color alone does not require immediate follow-up unless it is accompanied by other signs of distress such as cyanosis, pallor or jaundice.
D. NAS score.
NAS score is a tool used to assess the severity of withdrawal symptoms in infants with NAS. It includes items such as tremors, irritability, sleep problems, muscle tone, reflexes, seizures, yawning, sneezing, feeding, vomiting, stooling and temperature. A high NAS score indicates that the baby needs more intensive treatment such as medication to ease the withdrawal process. A low NAS score indicates that the baby is coping well and may not need medication. The NAS score should be monitored frequently and adjusted according to the baby's response.
E. Temperature.
The normal temperature range for a newborn is 36.5 to 37.5°C (97.7 to 99.5°F). The baby's temperature is high, which could indicate infection, dehydration or hyperthermia. This requires immediate follow-up to identify and treat the cause.
F. Oxygen saturation.
The normal oxygen saturation range for a newborn is 95 to 100%. The baby's oxygen saturation is within the normal range and does not require immediate follow-up unless it drops below 90% or rises above 100%, which could indicate hypoxia or hyperoxia respectively.
G. Central nervous system disturbances.
Central nervous system disturbances such as seizures, tremors, irritability and overactive reflexes are common symptoms of NAS. These symptoms are not life-threatening and can be managed with supportive care such as swaddling, rocking, dimming lights and reducing noise.
H. Respiratory rate.
The normal respiratory rate range for a newborn is 40 to 60 breaths per minute. The baby's respiratory rate is high, which could indicate respiratory distress, infection, pain or anxiety. This requires immediate follow-up to identify and treat the cause.
Full Explanation
Choice A:
Blood pressure. The normal blood pressure range for a newborn is 60 to 80 mm Hg systolic and 40 to 50 mm Hg diastolic. The baby's blood pressure is low, which could indicate shock, dehydration, infection, or heart failure. This requires immediate follow-up to identify and treat the cause.
Choice B:
Gastrointestinal disturbances. Gastrointestinal disturbances such as vomiting and diarrhea are common symptoms of neonatal abstinence syndrome (NAS), which is a withdrawal syndrome of infants after birth caused by in-utero exposure to drugs of dependence, most commonly opioids. These symptoms are not life-threatening and can be managed with supportive care such as hydration, nutrition, and comfort measures.
Choice C:
Skin color. Skin color is not a reliable indicator of NAS, as it can vary depending on the baby's ethnicity, temperature, oxygenation, and circulation. Skin color alone does not require immediate follow-up unless it is accompanied by other signs of distress such as cyanosis, pallor, or jaundice.
Choice D:
NAS score. NAS score is a tool used to assess the severity of withdrawal symptoms in infants with NAS. It includes items such as tremors, irritability, sleep problems, muscle tone, reflexes, seizures, yawning, sneezing, feeding, vomiting, stooling and temperature. A high NAS score indicates that the baby needs more intensive treatment such as medication to ease the withdrawal process. A low NAS score indicates that the baby is coping well and may not need medication. The NAS score should be monitored frequently and adjusted according to the baby's response.
Choice E:
Temperature. The normal temperature range for a newborn is 36.5 to 37.5°C (97.7 to 99.5°F). The baby's temperature is high, which could indicate infection, dehydration or hyperthermia. This requires immediate follow-up to identify and treat the cause.
Choice F:
Oxygen saturation. The normal oxygen saturation range for a newborn is 95 to 100%. The baby's oxygen saturation is within the normal range and does not require immediate follow- up unless it drops below 90% or rises above 100%, which could indicate hypoxia or hyperoxia respectively.
Choice G:
Central nervous system disturbances. Central nervous system disturbances such as seizures, tremors, irritability, and overactive reflexes are common symptoms of NAS. These symptoms are not life-threatening and can be managed with supportive care such as swaddling, rocking, dimming lights, and reducing noise.
Choice H:
Respiratory rate. The normal respiratory rate range for a newborn is 40 to 60 breaths per minute. The baby's respiratory rate is high, which could indicate respiratory distress, infection, pain, or anxiety. This requires immediate follow-up to identify and treat the cause.
A newborn is most interested in eating in which wake and sleep state?
A. Drowsy.
This is not the best state for feeding a newborn, because the baby may fall asleep before finishing the feed or may not latch on well. A drowsy baby may also have trouble swallowing or coordinating sucking and breathing. •
B. Crying.
This is also not a good state for feeding a newborn, because crying is a late sign of hunger and indicates that the baby is already distressed. A crying baby may have difficulty calming down enough to feed or may gulp air and become gassy. •
C. Active alert.
This is a possible state for feeding a newborn, but not the most optimal one. An active alert baby may be easily distracted by noises or movements around them or may become fussy or overstimulated if they are not fed quickly enough. •
D. Alert.
This is the best state for feeding a newborn because the baby is awake, calm, and attentive to their surroundings. An alert baby will show signs of hunger such as rooting, smacking their lips, or sucking their fingers, and will be ready to latch on and feed well.
Full Explanation
Choice A reason:
Drowsy. This is not the best state for feeding a newborn, because the baby may fall asleep before finishing the feed or may not latch on well. A drowsy baby may also have trouble swallowing or coordinating sucking and breathing. •
Choice B reason:
Crying. This is also not a good state for feeding a newborn, because crying is a late sign of hunger and indicates that the baby is already distressed. A crying baby may have difficulty calming down enough to feed or may gulp air and become gassy. •
Choice C reason:
Active alert. This is a possible state for feeding a newborn, but not the most optimal one. An active alert baby may be easily distracted by noises or movements around them or may become fussy or overstimulated if they are not fed quickly enough. •
Choice D reason:
Alert. This is the best state for feeding a newborn because the baby is awake, calm, and attentive to their surroundings. An alert baby will show signs of hunger such as rooting, smacking their lips, or sucking their fingers, and will be ready to latch on and feed well.
A nurse is reinforcing teaching about appropriate exercises during pregnancy with a client who is at 24 weeks of gestation. Which of the following statements indicates a need for additional teaching?
A. "I can continue my daily swimming routine.”.
Swimming is one of the best and safest exercises for pregnant women. It exercises your large muscle groups, provides cardiovascular benefits, reduces swelling, and allows you to feel weightless. Swimming is also a low-impact exercise that does not put too much stress on your joints and muscles. Therefore, this statement does not indicate a need for additional teaching.
B. "I will participate in a game of racquetball once a week.”.
Racquetball is not an appropriate exercise during pregnancy. It is a high-impact sport that involves sudden changes of direction, quick movements, and risk of falling or getting hit by the ball or the racquet. These factors can increase the chance of injury, bleeding, or premature labor. Therefore, this statement indicates a need for additional teaching.
C. "I can go cycling daily.”.
Cycling on a stationary bike is a safe exercise during pregnancy. It provides moderate aerobic conditioning and relieves stress and tension In your joints and muscles. Cycling on a stationary bike also reduces the risk of falling or losing balance compared to cycling on a regular bike. Therefore, this statement does not indicate a need for additional teaching.
D. "I will attend a yoga class three times per week.".
Yoga is a beneficial exercise during pregnancy. It can help you relax, improve your flexibility, strengthen your muscles, and prepare your body for labor and delivery. Yoga can also help you cope with symptoms of depression and anxiety during pregnancy. However, you should avoid hot yoga or poses that involve lying flat on your back, twisting your abdomen, or compressing your belly. Therefore, this statement does not indicate a need for additional teaching.
Full Explanation
Choice A reason:
Swimming is one of the best and safest exercises for pregnant women. It exercises your large muscle groups, provides cardiovascular benefits, reduces swelling, and allows you to feel weightless. Swimming is also a low-impact exercise that does not put too much stress on your joints and muscles. Therefore, this statement does not indicate a need for additional teaching.
Choice B reason:
Racquetball is not an appropriate exercise during pregnancy. It is a high-impact sport that involves sudden changes of direction, quick movements, and the risk of falling or getting hit by the ball or the racquet. These factors can increase the chance of injury, bleeding, or premature labor. Therefore, this statement indicates a need for additional teaching.
Choice C reason:
Cycling on a stationary bike is a safe exercise during pregnancy. It provides moderate aerobic conditioning and relieves stress and tension in your joints and muscles. Cycling on a stationary bike also reduces the risk of falling or losing balance compared to cycling on a regular bike. Therefore, this statement does not indicate a need for additional teaching.
Choice D reason:
Yoga is a beneficial exercise during pregnancy. It can help you relax, improve your flexibility, strengthen your muscles, and prepare your body for labor and delivery. Yoga can also help you cope with symptoms of depression and anxiety during pregnancy. However, you should avoid hot yoga or poses that involve lying flat on your back, twisting your abdomen, or compressing your belly. Therefore, this statement does not indicate a need for additional teaching.