The nurse is caring for a small-for-gestational-age infant born to a drug-dependent client. Which manifestations should the nurse assess as evidence of withdrawal symptoms in the newborn?

Choice A rationale Lethargy and hypotonia, meaning decreased muscle tone, are manifestations often associated with central nervous system depression, which can occur with maternal opioid or other sedative drug use. However, the classic withdrawal syndrome, Neonatal Abstinence Syndrome (NAS), is characterized by hyperirritability and hypertonia, indicating CNS hyperexcitability, not lethargy. Lethargy suggests a non-withdrawing or severely depressed infant. Choice B rationale Hyporeflexia, which is diminished reflexes, and bradycardia, a slower than normal heart rate (newborn resting rate is 120-160 beats per minute), are not typical signs of withdrawal. NAS is a hyper-excited state, usually presenting with hyperreflexia and tachycardia (heart rate > 160 beats per minute) due to sympathetic overstimulation. Choice C rationale A sluggish or slow respiratory rate (newborn rate is 30-60 breaths per minute) is typically indicative of central nervous system depression or potential respiratory compromise, which is the opposite of the hyperactive state seen in withdrawal. Withdrawal often causes tachypnea, or a fast respiratory rate, as a sign of metabolic distress and increased demand. Choice D rationale Tremors, along with jitteriness or myoclonic jerks, are common and significant signs of the central nervous system hyperirritability that defines Neonatal Abstinence Syndrome (NAS). These uncoordinated movements are a direct result of the newborn's system reacting to the removal of maternally used opioid or other drugs. Choice E rationale Constant movement, including hyperactivity, exaggerated Moro reflex, and uncoordinated sucking, is a hallmark manifestation of the hyper-excitable state of the central nervous system in a newborn experiencing drug withdrawal (NAS). This is caused by the sympathetic nervous system overdrive upon removal of the depressant drug. Choice F rationale A high-pitched, shrill cry, often excessive and non-soothing, is a classic and very characteristic sign of the central nervous system hyperirritability seen in newborns with Neonatal Abstinence Syndrome (NAS). This distinctive cry is a key indicator of the neurological distress caused by drug withdrawal.