A nurse is planning care for a newborn who has neonatal abstinence syndrome. Which of the following interventions should the nurse include in the plan of care?

Correct Answer: D

Rationale: Neonatal abstinence syndrome (NAS) occurs in newborns who were exposed to addictive drugs in utero, commonly seen in infants born to mothers with substance use disorders. These babies often experience withdrawal symptoms such as tremors, irritability, and difficulty sleeping. Swaddling the newborn in a flexed position can help provide comfort and security to the infant, which may help alleviate some of the withdrawal symptoms they are experiencing. This intervention can also mimic the snug environment of the womb, promoting a sense of calmness for the newborn. It is important to create a soothing environment to aid in the management of NAS symptoms.

Correct Answer: A

Rationale: In this situation, it is important for the nurse to provide the client with options for how they would like to proceed. By offering the option to bathe and dress the baby, the nurse is allowing the client to make decisions about their care and how they would like to cope with the loss. This empowers the client and respects their individual grieving process. It is crucial to encourage the client to make choices that align with their feelings and provide them with support and sensitivity during this difficult time.

Correct Answer: B

Rationale: Ensuring the newborn's mouth is wide open before latching to the breast is the correct action to take when caring for a client experiencing sore nipples from breastfeeding. When the newborn latches onto the breast correctly with a wide open mouth, it helps to prevent nipple soreness and discomfort by allowing proper positioning and attachment, which reduces pressure on the nipple. This action can promote effective and comfortable breastfeeding for both the client and the newborn. Placing a snug dressing on the nipple when not breastfeeding (Choice A) could hinder air circulation, leading to moisture, which may increase the risk of nipple soreness. Limiting the newborn's feeding to 10 minutes on each breast (Choice C) can be insufficient for adequate milk intake and can lead to feeding issues. Instructing the client to begin the feeding with the nipple that is most tender (Choice D) may exacerbate the issue and cause further discomfort.

Correct Answer: B

Rationale: Neonatal opioid withdrawal syndrome, also known as neonatal abstinence syndrome (NAS), can occur in newborns who were exposed to opioids in utero. Symptoms of NAS can include tremors, irritability, high-pitched crying, poor feeding, vomiting, diarrhea, sweating, and sneezing. The severity of symptoms can vary depending on the type of opioid exposure, dosage, and duration of exposure. In this case, the nurse should expect to see moderate tremors of the extremities in the newborn experiencing opioid withdrawals at 48 hours old. It is important for the nurse to monitor and manage the newborn's withdrawal symptoms closely to ensure their safety and well-being.

Correct Answer: C

Rationale: A school-based mothers' program can assist a pregnant teen in establishing a stable identity by providing specialized support and resources tailored to their unique needs. These programs typically offer academic assistance, childcare services, counseling, and parenting classes. By being in a supportive and understanding environment with other young mothers, the pregnant teen can feel accepted and supported, which can help boost her self-esteem and confidence. Additionally, these programs often focus on empowering young mothers to continue their education and set goals for their future, contributing to the development of a stable identity.