a nurse is assessing a newborn who is 48 hr old and is experiencing opioid withdrawals which of the following findings should the nurse expect
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Nursing Elites

ATI LPN

PN ATI Capstone Maternal Newborn

1. A healthcare provider is assessing a newborn who is 48 hours old and is experiencing opioid withdrawals. Which of the following findings should the healthcare provider expect?

Correct answer: B

Rationale: The correct answer is B: Moderate tremors of the extremities. In newborns experiencing opioid withdrawals, moderate tremors of the extremities are a common sign. Other signs of opioid withdrawal in newborns may include irritability, feeding difficulties, and gastrointestinal disturbances. Choice A, hypotonia, is not typically associated with opioid withdrawal in newborns. Choice C, an axillary temperature of 36.1°C (96.9°F), falls within the normal range for newborns and is not specifically indicative of opioid withdrawal. Choice D, excessive crying, is not a typical sign of opioid withdrawal in newborns.

2. A client with lactose intolerance needs to increase calcium intake. Which food should the nurse recommend?

Correct answer: A

Rationale: Spinach is a suitable choice to recommend for increasing calcium intake to a client with lactose intolerance. Spinach is a good non-dairy source of calcium. Peanut butter, ground beef, and carrots are not significant sources of calcium. Peanut butter is high in protein and fats, ground beef is a source of protein and iron, and carrots are rich in vitamin A and fiber, but none of these choices provide a substantial amount of calcium.

3. A home health nurse is providing teaching to a family of a client who has seizure manifestations as a result of an inoperable brain tumor. What intervention should the nurse include in the teaching?

Correct answer: C

Rationale: The correct intervention the nurse should include in the teaching is to pad the side rails of the bed. By padding the side rails, the nurse can help prevent injury if the patient experiences a seizure. Administering antiseizure medications promptly (Choice A) is typically the responsibility of a healthcare provider or according to a prescribed schedule. Using oral airway devices during seizures (Choice B) can pose risks and should be managed by healthcare professionals. Applying restraints during a seizure (Choice D) is not recommended as it can lead to further injury and complications.

4. A client is admitted for observation and has full range of motion. Which is the best manner to encourage the client to void?

Correct answer: D

Rationale: The correct answer is D: Client Bathroom. Encouraging the client to use the bathroom is the best way to promote independence and privacy, maintaining normal function. In this case, since the client has full range of motion, using the client bathroom would be the most appropriate choice. Options A, B, and C (Urinal, Bedpan, Bedside Commode) are not the best choices as they may restrict the client's independence and privacy, which can impact their psychological well-being and normal voiding function.

5. A nurse is teaching a client about the use of levetiracetam. Which of the following should be included in the teaching?

Correct answer: B

Rationale: The correct answer is B. Levetiracetam can cause mood changes and behavioral side effects, so clients should be monitored for these effects. Choice A is incorrect because levetiracetam is not typically associated with weight loss. Choice C is incorrect as levetiracetam is a prescription medication, not available over the counter. Choice D is incorrect as all medications, including levetiracetam, have potential side effects.

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