Question

A nurse is caring for a newborn who is 70 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 pregnanc

Vital Signs
0700:Heart rate 156/minRespiratory rate 58/minTemperature 37.2° C (98.9° F) Oxygen saturation 98% on room air100:Heart rate 160/minRespiratory rate 60/minTemperature 37.3° C (99.2° F) Oxygen saturation 96% on room air
Physical Examination
1100:Newborn is inconsolable with a high-pitched cry. Newborn sucks vigorously on pacifier but breastfeeds poorly. Respirations unlabored. Lungs sound clear on auscultation. Increased muscle tone with moderate to severe tremors when disturbed. Hyperactive Moro reflex noted. Several loose stools today.
Diagnostic Results
Maternal urine toxicology screen positive for opiates (negative)Newborn urine toxicology screen positive for opiates (negative)

Which of the following findings should the nurse report to the provider?
Select all that apply.

Answer 1

The nurse should report findings indicative of neonatal abstinence syndrome, such as the newborn's inconsolable high-pitched cry, poor breastfeeding, increased muscle tone, hyperactive Moro reflex, and several loose stools.

Step-by-step explanation:

The nurse should report several findings to the provider that may indicate the newborn is experiencing withdrawal symptoms due to the maternal history of methadone use during pregnancy. These findings include the newborn's inconsolable high-pitched cry, poor breastfeeding, increased muscle tone with moderate to severe tremors when disturbed, hyperactive Moro reflex, and the presence of several loose stools. These symptoms align with neonatal abstinence syndrome (NAS), a condition in newborns exposed to opiates in utero.