Page 855 - Saunders Comprehensive Review For NCLEX-RN

275. Answer: 3, 4, 5

Rationale: A newborn of a woman who uses drugs is irritable. The infant is
overloaded easily by sensory stimulation. The infant may cry incessantly and be
difficult to console. The infant would hyperextend and posture rather than cuddle
when being held. This infant is not lethargic or sleepy.
Test-Taking Strategy: Lethargy and sleepiness are comparable or alike in that
they indicate hypoactivity of the newborn, and therefore can be eliminated. From the
remaining options, recalling the pathophysiology associated with an infant born to a
drug-addicted mother and that the newborn is irritable will assist you in eliminating
that this infant will be easily comforted and cuddle when held.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Assessment
Content Area: Maternity: Newborn
Health Problem: Newborn: Addicted Newborn
Priority Concepts: Addiction; Clinical Judgment
Reference: Hockenberry, Wilson, Rodgers (2017), pp. 284-285.

276. Answer: 2

Rationale: Fetal alcohol syndrome, a diagnostic category of fetal alcohol spectrum
disorders (FASDs), is caused by maternal alcohol use during pregnancy. Features of
newborns diagnosed with fetal alcohol syndrome include craniofacial abnormalities,
intrauterine growth restriction, cardiac abnormalities, abnormal palmar creases, and
respiratory distress. Options 1, 3, and 4 are normal assessment findings in the full-
term newborn infant.
Test-Taking Strategy: Use knowledge regarding normal assessment findings in
the full-term newborn infant to answer this question. Length, birth weight, and head
circumference are comparable or alike in that all are physical measurements
assessed on a newborn and represent normal findings in a full-term newborn.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Assessment
Content Area: Maternity: Newborn
Health Problem: Newborn: Addicted Newborn
Priority Concepts: Addiction; Clinical Judgment
Reference: Hockenberry, Wilson, Rodgers (2017), p. 290.

277. Answer: 4

Rationale: Fetal alcohol syndrome, a diagnostic category delineated under fetal
alcohol spectrum disorders (FASDs), is caused by maternal alcohol use during
pregnancy. A primary nursing goal for the newborn diagnosed with fetal alcohol
syndrome is to establish nutritional balance after birth. These newborns may exhibit
hyperirritability, vomiting, diarrhea, or an uncoordinated sucking and swallowing
ability. A quiet environment with minimal stimuli and handling would help

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