A one-day-old newborn diagnosed with intrauterine growth retardation is observed by the nurse to be restless, irritable, fist-sucking, and having a high-pitched, shrill cry. Based on this data, which of the following actions should the nurse take FIRST?
(1) Discourage stimulation of the baby by rocking.
(2) Tightly swaddle the infant in a flexed position.
(3) Schedule feeding times every three to four hours.
(4) Encourage eye contact with the infant during feedings.
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The Correct Answer to the Question above is: (2)
Reworded question: What do you do for a newborn experiencing withdrawal?
Strategy: Determine the outcome of each answer.
Needed Info: Drug withdrawal may manifest from as early as 12-24 hrs after birth up to 7-10 days after delivery. Symptoms: high-pitched cry, hyperreflexia, decreased sleep, diaphoresis, tachypnea, excessive mucus, vomiting, uncoordinated sucking. Nursing care: assess muscle tone, irritability, vital signs; administer phenobarbital as ordered; report symptoms of respiratory distress; reduce stimulation; provide adequate nutrition/fluids; monitor mother/child interactions.
Category: Implementation/Health Promotion and Maintenance
(1) Discourage stimulation of the baby by rocking.—Rocking helps the infant feel more comfortable.
(2) Tightly swaddle the infant in a flexed position.—CORRECT: Promotes infant's comfort and security.
(3) Schedule feeding times every three to four hours.—Small, frequent feedings are preferable.
(4) Encourage eye contact with the infant during feedings.—May result in overstimulation of infant.
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