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 is being taught about the use of metformin. Which of the following should be included?

Correct answer: A

Rationale: Corrected Rationale: Metformin should be taken with food to minimize gastrointestinal side effects. Choice A is the correct answer as taking metformin with meals can help reduce the likelihood of experiencing gastrointestinal side effects like diarrhea and nausea, which are common side effects of metformin. Choice B is incorrect because metformin actually helps lower blood sugar levels and does not cause hyperglycemia. Choice C is incorrect as metformin is usually taken twice or even three times a day, not just once daily. Choice D is incorrect because metformin is an oral medication, not an injectable one.

3. A client is at high risk for iron deficiency anemia. Which of the following foods should the nurse instruct the client to increase in their diet?

Correct answer: C

Rationale: The correct answer is C: Raisins. Raisins are a good source of iron, which can help prevent or address iron deficiency anemia. Yogurt (Choice A) and cheddar cheese (Choice D) are not significant sources of iron. While apples (Choice B) are a healthy fruit, they do not contain as much iron as raisins.

4. A nurse is caring for a 7-month-old infant being treated for severe dehydration. Which finding indicates treatment has been effective?

Correct answer: B

Rationale: A flat anterior fontanel indicates improved hydration in infants, as dehydration typically causes sunken fontanels.

5. A patient is scheduled for cataract surgery but decides to cancel, stating 'I see just fine.' Which of the following responses should the nurse make?

Correct answer: B

Rationale: The correct response is to encourage the patient to share more about their concerns. This approach helps the nurse understand the patient's perspective and allows for a supportive discussion. Choice A is dismissive and does not address the patient's feelings. Choice C may undermine the patient's autonomy and decision-making. Choice D suggests delaying without addressing the patient's current decision.

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