Newborn delivered by repeat cesarean birth at 40 weeks of gestation.Birth weight 3,515 g (7 lb 12 oz)Apgar scores 8 at 1
min and 9 at 5 minMaternal history of methadone use during pregnancy.
1100:Newborn is inconsolable with a high-pitched cry. Newborn sucks vigorously on pacifier but breastfeeds poorly.
Increased muscle tone with moderate to severe tremors when disturbed. Hyperactive Moro reflex noted. Mottled skin noted
on extremities. Frequent sneezing. Several loose stools today.
Maternal urine toxicology screen: positive for opiates (negative)
The nurse is planning to contact the provider regarding the newborn's status. Which of the following prescriptions regarding
the newborn should the nurse anticipate?
Administer scheduled doses of oral morphine.
Maintain a low-stimulus environment.
Initiate neonatal abstinence syndrome (NAS) scoring.
A nurse is caring for a client who is at 35 weeks of gestation and has placenta previa. Which of the following actions should
the nurse take?
Initiate continuous external fetal monitoring.
A nurse is providing education about family bonding to guardians who recently adopted a newborn. The nurse should make
which of the following suggestions to aid the family's 7-year-old child in accepting the new family member?
Obtain a gift from the newborn to present to the sibling.
,A nurse is caring for a prenatal client who has parvovirus B19 (fifth disease). Which of the following actions should the
nurse take?
Schedule an ultrasound.
A nurse is caring for a client who is at 26 weeks of gestation and has epilepsy. The nurse enters the room and observes the
client having a seizure. After turning the client's head to one side, which of the following actions should the nurse take
immediately after the seizure?
Administer oxygen via a nonrebreather mask.
A nurse is teaching a client who is in preterm labor about terbutaline. Which of the following statements by the client
indicates an understanding of the teaching?
"I will have blood tests because my potassium might decrease."
A nurse is providing teaching to a client who is at 40 weeks of gestation and has a new prescription for misoprostol. Which
of the following instructions should the nurse include in the teaching?
"I can administer oxytocin 4 hours after the insertion of the medication."
, A nurse is performing a newborn assessment. Which of the following images should the nurse identify as an indication of
spina bifida occulta?
External indications of this neural tube defect include a dimpled area over the defect and the presence of a birthmark or
hairy patch above the area.
A nurse is planning discharge for a client who is 3 days postpartum. Which of the following nonpharmacological
interventions should the nurse include in the plan of care for lactation suppression?
Apply cabbage leaves to the breasts.
A nurse is assessing a newborn who is 12 hr old. Which of the following manifestations requires intervention by the nurse?
Substernal chest retractions while sleeping.
A nurse is assessing a client who has preeclampsia with severe features. Which of the following manifestations should the
nurse expect?
Blurred vision
A nurse is speaking with a client who is trying to make a decision about tubal ligation. The client asks, "What effects will
this procedure have on my sex life?" Which of the following responses should the nurse make?
"This procedure should have no effect on your sexual performance or adequacy."
min and 9 at 5 minMaternal history of methadone use during pregnancy.
1100:Newborn is inconsolable with a high-pitched cry. Newborn sucks vigorously on pacifier but breastfeeds poorly.
Increased muscle tone with moderate to severe tremors when disturbed. Hyperactive Moro reflex noted. Mottled skin noted
on extremities. Frequent sneezing. Several loose stools today.
Maternal urine toxicology screen: positive for opiates (negative)
The nurse is planning to contact the provider regarding the newborn's status. Which of the following prescriptions regarding
the newborn should the nurse anticipate?
Administer scheduled doses of oral morphine.
Maintain a low-stimulus environment.
Initiate neonatal abstinence syndrome (NAS) scoring.
A nurse is caring for a client who is at 35 weeks of gestation and has placenta previa. Which of the following actions should
the nurse take?
Initiate continuous external fetal monitoring.
A nurse is providing education about family bonding to guardians who recently adopted a newborn. The nurse should make
which of the following suggestions to aid the family's 7-year-old child in accepting the new family member?
Obtain a gift from the newborn to present to the sibling.
,A nurse is caring for a prenatal client who has parvovirus B19 (fifth disease). Which of the following actions should the
nurse take?
Schedule an ultrasound.
A nurse is caring for a client who is at 26 weeks of gestation and has epilepsy. The nurse enters the room and observes the
client having a seizure. After turning the client's head to one side, which of the following actions should the nurse take
immediately after the seizure?
Administer oxygen via a nonrebreather mask.
A nurse is teaching a client who is in preterm labor about terbutaline. Which of the following statements by the client
indicates an understanding of the teaching?
"I will have blood tests because my potassium might decrease."
A nurse is providing teaching to a client who is at 40 weeks of gestation and has a new prescription for misoprostol. Which
of the following instructions should the nurse include in the teaching?
"I can administer oxytocin 4 hours after the insertion of the medication."
, A nurse is performing a newborn assessment. Which of the following images should the nurse identify as an indication of
spina bifida occulta?
External indications of this neural tube defect include a dimpled area over the defect and the presence of a birthmark or
hairy patch above the area.
A nurse is planning discharge for a client who is 3 days postpartum. Which of the following nonpharmacological
interventions should the nurse include in the plan of care for lactation suppression?
Apply cabbage leaves to the breasts.
A nurse is assessing a newborn who is 12 hr old. Which of the following manifestations requires intervention by the nurse?
Substernal chest retractions while sleeping.
A nurse is assessing a client who has preeclampsia with severe features. Which of the following manifestations should the
nurse expect?
Blurred vision
A nurse is speaking with a client who is trying to make a decision about tubal ligation. The client asks, "What effects will
this procedure have on my sex life?" Which of the following responses should the nurse make?
"This procedure should have no effect on your sexual performance or adequacy."
