Author Question: A nurse assessing an infant notes that the baby is jittery, has muscle twitches, and has jittery ... (Read 135 times)

jace · **on:** Jun 28, 2018

A nurse assessing an infant notes that the baby is jittery, has muscle twitches, and has jittery movement of the arms and legs. What action by the nurse is most appropriate?

A.
Call the physician and request muscle relaxants.
B.
Ensure the infant is kept warm in a quiet environment.
C.
Facilitate completion of either a CT or an MRI scan.
D.
Request laboratory work to detect substances of abuse.

Question 2

The perinatal nurse notes that a newborn does not seem to have an opening inside the anal ring. Which action by the nurse takes priority?

A.
Ask the mother how well the infant is eating.
B.
Assess the abdomen and notify the physician.
C.
Facilitate laboratory studies for kidney function.
D.
Reassure the parents that this is a normal deviation.

uniquea123 · **Reply #1 on:** Jun 28, 2018

Answer to Question 1

ANS: D
Hypertonia is characterized by muscle tremors, twitches, or jerkiness, and this finding is often associated with neonatal abstinence syndrome. The nurse should notify the health-care provider and request a drug screen. A warm, quiet environment may be best for this infant, but this action is not the priority. Muscle relaxants and scanning tests are not warranted.

Answer to Question 2

ANS: B
This infant may have an imperforate anus, a condition that is an emergency, as the infant cannot pass stool. The nurse should quickly assess the baby's abdomen for distention and firmness and notify the physician or health-care provider. The other actions are not warranted.