Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
Which nursing interventions are appropriate while caring for a newborn whose mother was addicted to heroin during the pregnancy? (Select All that Apply.)
A. Offer the newborn a pacifier
Offer the newborn a pacifier. This can help soothe the newborn and provide comfort, as infants exposed to opioids in utero often exhibit increased need for sucking.
B. Observe the newborn in a well-lit nursery
Observe the newborn in a well-lit nursery. This is not appropriate as bright lights can overstimulate and distress the newborn.
C. Maintain low stimulation environment
Maintain a low stimulation environment. This helps reduce stress and irritability in newborns undergoing withdrawal, who can be hypersensitive to stimuli.
D. Administer oral glucose for comfort
Administer oral glucose for comfort. Glucose is not typically used for comfort in NAS management; comforting measures like swaddling and pacifiers are preferred.
E. Swaddle newborn tightly
Swaddle the newborn tightly. Tight swaddling can provide a sense of security and help manage symptoms of neonatal abstinence syndrome (NAS) by reducing irritability and promoting sleep.
F. Feed the infant half strength formula
Feed the infant half-strength formula. Infants with NAS usually require regular, full-strength formula to meet nutritional needs unless otherwise indicated by specific feeding issues.
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Full Explanation
A. Offer the newborn a pacifier. This can help soothe the newborn and provide comfort, as infants exposed to opioids in utero often exhibit increased need for sucking.
B. Observe the newborn in a well-lit nursery. This is not appropriate as bright lights can overstimulate and distress the newborn.
C. Maintain a low stimulation environment. This helps reduce stress and irritability in newborns undergoing withdrawal, who can be hypersensitive to stimuli.
D. Administer oral glucose for comfort. Glucose is not typically used for comfort in NAS management; comforting measures like swaddling and pacifiers are preferred.
E. Swaddle the newborn tightly. Tight swaddling can provide a sense of security and help manage symptoms of neonatal abstinence syndrome (NAS) by reducing irritability and promoting sleep.
F. Feed the infant half-strength formula. Infants with NAS usually require regular, full-strength formula to meet nutritional needs unless otherwise indicated by specific feeding issues.
Similar Questions
The nurse is caring for a newborn born at 31 weeks' gestation. Which assessment finding should the nurse anticipate?
A. Sole creases on heels
Sole creases on heels. Sole creases are a sign of maturity and are usually present in full-term infants, not preterm.
B. Ruddy skin color
Ruddy skin color. This is more common in infants with polycythemia or those who are small for gestational age, not specifically linked to prematurity.
C. Flexion of all four (4) extremities
Flexion of all four extremities. Premature infants typically have less muscle tone and may exhibit less flexion, often appearing more limp or having extended extremities.
D. Scant amount of vernix caseosa
Scant amount of vernix caseosa. Premature infants typically have more vernix caseosa, which protects their delicate skin in utero. The amount decreases closer to full term, but at 31 weeks, there may still be a moderate amount.
Full Explanation
A. Sole creases on heels. Sole creases are a sign of maturity and are usually present in full-term infants, not preterm.
B. Ruddy skin color. This is more common in infants with polycythemia or those who are small for gestational age, not specifically linked to prematurity.
C. Flexion of all four extremities. Premature infants typically have less muscle tone and may exhibit less flexion, often appearing more limp or having extended extremities.
D. Scant amount of vernix caseosa. Premature infants typically have more vernix caseosa, which protects their delicate skin in utero. The amount decreases closer to full term, but at 31 weeks, there may still be a moderate amount.
The nurse knows that which of the following is not a cause of mastitis?
A. Oversupply of milk
Oversupply of milk. This can lead to milk stasis and blockage, which can increase the risk of mastitis.
B. Gradual weaning of breastfeeding
Gradual weaning of breastfeeding. Gradual weaning typically helps reduce the risk of mastitis because it allows the milk supply to decrease slowly and naturally without engorgement or blockage.
C. Infrequent, inconsistent feedings
Infrequent, inconsistent feedings. This can lead to milk stasis and is a common cause of mastitis.
D. Cracks or fissures of the nipples
Cracks or fissures of the nipples. These can provide an entry point for bacteria, leading to infection and mastitis.
Full Explanation
A. Oversupply of milk. This can lead to milk stasis and blockage, which can increase the risk of mastitis.
B. Gradual weaning of breastfeeding. Gradual weaning typically helps reduce the risk of mastitis because it allows the milk supply to decrease slowly and naturally without engorgement or blockage.
C. Infrequent, inconsistent feedings. This can lead to milk stasis and is a common cause of mastitis.
D. Cracks or fissures of the nipples. These can provide an entry point for bacteria, leading to infection and mastitis.
A child with a heart defect is placed on a maintenance dose of Lanoxin elixir. The ordered dose is 0.07mg/kg/day in 2 divided doses. The child weighs 19 pounds. What is the maximum amount of medication that will be given per dose by the nurse?
Full Explanation
Convert weight from pounds to kilograms:
19pounds÷2.2=8.64kg
Calculate the total daily dose:
0.07mg/kg/day×8.64kg=0.6048mg/day
Divide the daily dose into two doses:
0.6048mg/day÷2=0.3024mg/dose
Round off the dose to two decimal places:
0.3024mg≈0.30mg
The maximum amount of medication per dose is 0.3 mg.