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.
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.
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