A nurse is assisting in the care of a newborn in the postpartum unit.
Complete the following sentence by using the lists of options.
The nurse should first address the newborn's
The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"D"}
? Rationale for Correct Answers
Glucose level is the priority because the newborn’s blood glucose is 35 mg/dL, which is below the normal threshold of 40–45 mg/dL. Neonatal hypoglycemia can lead to seizures, apnea, and brain injury if untreated. Immediate intervention is critical to prevent neurologic damage.
Feeding difficulties are the next concern because they contribute to poor caloric intake and perpetuate hypoglycemia. The newborn exhibits poor latch, uncoordinated suck, and loose stools—hallmarks of neonatal abstinence syndrome (NAS), which impair feeding and weight gain.
❌ Rationale for Incorrect Response 1 Options
Respiratory rate (65/min) is mildly elevated but within the upper limit of normal for newborns (30–60/min). No signs of respiratory distress (e.g., nasal flaring, retractions, grunting) are present, making this a lower priority.
Heart rate (165/min) is within the normal neonatal range (120–160/min). Mild tachycardia can be attributed to irritability or crying and is not immediately life-threatening.
Temperature (37.5°C) is within the normal range for newborns (36.5–37.5°C). There is no evidence of fever or hypothermia requiring urgent intervention.
❌ Rationale for Incorrect Response 2 Options
Skin findings such as mottling are nonspecific and often seen in NAS or immature autonomic regulation. They are not immediately dangerous.
Cry characteristics like high-pitched crying are typical of NAS but are not life-threatening and do not require urgent intervention.
Tremors are a common NAS symptom but are not acutely harmful unless associated with seizures, which are not reported here.
? Take-Home Points
- Neonatal hypoglycemia (<40 mg/dL) is a medical emergency requiring prompt correction to prevent neurologic injury.
- Feeding difficulties in NAS exacerbate hypoglycemia and must be addressed to ensure adequate caloric intake.
- NAS presents with autonomic, gastrointestinal, and neurologic symptoms; diagnosis is clinical and supported by maternal and neonatal drug screens.
- NAS must be differentiated from neonatal sepsis, hypoxic-ischemic encephalopathy, and metabolic disorders, which may present similarly.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
A nonstress test (NST) typically takes 20 to 40 minutes to complete, not 2 to 4 hours. The duration is usually sufficient to observe fetal heart rate accelerations in response to fetal movement, which is the primary indicator of fetal well-being during the test.
Choice B rationale
A nonstress test is performed to assess fetal well-being, especially in pregnancies at risk for uteroplacental insufficiency, such as those with post-term gestation, pre-eclampsia, or diabetes, not specifically because it is a first pregnancy.
Choice C rationale
The nonstress test primarily measures the fetal heart rate patterns in response to fetal movement. Contraction strength is measured during a contraction stress test or by internal uterine pressure catheter, which is a different diagnostic procedure.
Choice D rationale
The nonstress test evaluates the fetal heart rate accelerations in response to spontaneous fetal movement. This indicates a healthy central nervous system and adequate oxygenation of the fetus. A reactive NST shows at least two accelerations of 15 bpm above baseline, lasting at least 15 seconds, within a 20-minute period.
Correct Answer is A
Explanation
Choice A rationale
Nalbuphine hydrochloride is an opioid agonist-antagonist analgesic that primarily acts on kappa opioid receptors, producing analgesia, and partially on mu opioid receptors, which can lead to adverse effects like sedation. Sedation is a common central nervous system depressant effect of opioid medications due to their action on specific brainstem and cortical regions, altering neurotransmission and decreasing overall neuronal excitability. The degree of sedation can vary depending on the dosage and individual patient sensitivity.
Choice B rationale
Fever is an elevated body temperature and is not a direct adverse effect typically associated with nalbuphine hydrochloride. Fever is more commonly indicative of an infectious process, inflammatory response, or certain drug reactions (e.g., drug fever), but it is not a direct pharmacological action or common side effect of opioid analgesics like nalbuphine. Opioids generally do not affect thermoregulation in a way that causes a fever.
Choice C rationale
Diarrhea is characterized by loose, watery stools and is not a common adverse effect of nalbuphine hydrochloride. Opioids, in general, are more known for causing constipation due to their effects on decreasing gastrointestinal motility and increasing fluid absorption in the intestines, by acting on opioid receptors in the enteric nervous system. Therefore, diarrhea would be an atypical and unexpected response to nalbuphine.
Choice D rationale
Diuresis refers to increased urine production and is not a typical adverse effect of nalbuphine hydrochloride. Opioids can sometimes affect antidiuretic hormone (ADH) secretion, potentially leading to fluid retention or oliguria rather than diuresis. Diuresis is usually associated with diuretic medications or certain physiological conditions that promote increased urine output, which is contrary to the expected effects of opioids on renal function.
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