Question

A nurse is caring for a newborn who is 72 hr old.

Medical History
Newborn delivered by repeat cesarean birth at 40 weeks of gestation.Birth weight 7 lb 12 oz (3,515 g)Apgar scores 8 at 1 min and 9 at 5 minMaternal history of methadone use during pregnancy.

Vital Signs
0700:Heart rate 156/minRespiratory rate 68/minTemperature 37.7° C (99.9° F) Oxygen saturation 97% on room air100:Heart rate 174/minRespiratory rate 84/minTemperature 38.2° C (100.8° F) Oxygen saturation 98% on room air
Physical Examination
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.
Diagnostic Results
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?
Select all that apply.

Answer 1

The nurse should contact the provider regarding the newborn's withdrawal symptoms from maternal opioid use during pregnancy.

Step-by-step explanation:

The nurse should anticipate contacting the provider regarding the newborn's status because the infant is displaying signs of withdrawal from methadone. The symptoms described, such as high-pitched cry, poor feeding, muscle tremors, hyperactive Moro reflex, mottled skin, frequent sneezing, and loose stools are consistent with withdrawal symptoms associated with maternal opioid use during pregnancy.

Apgar scores, which assess the baby's general well-being at 1 minute and 5 minutes after birth, were mentioned in the medical history, but they are not directly related to the nurse's plan of action. The nurse's concern in this situation is primarily related to the neonate's withdrawal symptoms and the need for appropriate medical intervention to manage the symptoms.

It is important for the nurse to report the infant's symptoms and the positive maternal urine toxicology screen for opiates to the provider so that the necessary medication can be prescribed to alleviate withdrawal symptoms and provide support for the newborn.