A nurse is assisting in the care of a newborn who is 72 hours old and is receiving treatment for neonatal abstinence syndrome.
Which of the following data collection findings should the nurse identify as requiring immediate follow-up? (Select all that apply.).
Blood pressure.
Gastrointestinal disturbances.
Skin color.
NAS score.
Temperature.
Oxygen saturation.
Central nervous system disturbances.
Respiratory rate
Correct Answer : B,D,F,H
Choice A:
Blood pressure is not a priority finding for a newborn with neonatal abstinence syndrome (NAS). Blood pressure may be slightly elevated or normal in NAS, but it is not a sign of severe withdrawal or a risk for complications. •
Choice B:
Gastrointestinal disturbances are common and serious symptoms of NAS. They include poor feeding, vomiting, diarrhea, dehydration and poor weight gain. These can lead to electrolyte imbalance, malnutrition and failure to thrive. This choice requires immediate follow-up. •
Choice C:
Skin color is not a priority finding for a newborn with NAS. Skin color may be normal or slightly pale in NAS, but it is not a sign of severe withdrawal or risk for complications. •
Choice D:
NAS score is a priority finding for a newborn with NAS. NAS score is a tool used to assess the severity of withdrawal symptoms and the need for pharmacological treatment. A high NAS score indicates that the newborn needs medication to manage the withdrawal and prevent complications such as seizures. This choice requires immediate follow-up. •
Choice E:
Temperature is not a priority finding for a newborn with NAS. The temperature may be slightly elevated or normal in NAS, but it is not a sign of severe withdrawal or risk for complications. •
Choice F:
Oxygen saturation is a priority finding for a newborn with NAS. Oxygen saturation measures the amount of oxygen in the blood. Low oxygen saturation can indicate respiratory distress, which is a common and serious symptom of NAS. Respiratory distress can lead to hypoxia, acidosis, and brain damage. This choice requires immediate follow-up. •
Choice G:
Central nervous system disturbances are common and serious symptoms of NAS. They include tremors, irritability, excessive crying, hyperactivity, increased muscle tone, seizures, and sleep problems. These can indicate severe withdrawal and risk for neurological damage. This choice requires immediate follow-up.
Choice H:
Respiratory rate is a priority finding for a newborn with NAS. The respiratory rate measures the number of breaths per minute. A high respiratory rate can indicate respiratory distress, which is a common and serious symptom of NAS. Respiratory distress can lead to hypoxia, acidosis, and brain damage. This choice requires immediate follow-up.
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Correct Answer is C
Explanation
Choice A reason:
Infection is not prevented by vitamin K administration. Vitamin K is needed for blood clotting, not for fighting infections. Newborns are given vitamin K injections to prevent a serious disease called hemorrhagic disease of the newborn (HDN), which is caused by bleeding in the brain or other organs.
Choice B reason:
Hyperbilirubinemia is not prevented by vitamin K administration. Hyperbilirubinemia is a condition in which there is too much bilirubin in the blood, causing jaundice. Bilirubin is a yellow pigment that is produced when red blood cells break down. Vitamin K does not affect the production or breakdown of bilirubin.
Choice C reason:
Bleeding is prevented by vitamin K administration. Vitamin K is needed for the synthesis of several clotting factors that help stop bleeding when there is an injury. Newborns have very low levels of vitamin K in their bodies because they do not get enough from the placenta or breast milk, and they do not have enough bacteria in their intestines to produce it. This puts them at risk for VKDB, which can cause life-threatening bleeding in the brain or other organs.
Choice D reason:
Potassium deficiency is not prevented by vitamin K administration. Potassium is an electrolyte that is important for nerve and muscle function, as well as fluid balance. Vitamin K does not affect the absorption or excretion of potassium.
Correct Answer is C
Explanation
Choice A reason:
Asymmetrical breathing is not a sign of meconium aspiration syndrome (MAS). It is a sign of diaphragmatic hernia, a condition where the abdominal organs push into the chest cavity and interfere with lung development.
Choice B reason:
Born before 38 weeks gestation is not a sign of MAS. It is a risk factor for respiratory distress syndrome (RDS), a condition where the lungs are not fully developed and lack surfactant, a substance that helps keep the air sacs open.
Choice C reason:
Yellow-green staining on the umbilical cord is a sign of MAS. It indicates that the baby has passed meconium into the amniotic fluid before or during birth and may have inhaled it into the lungs. Meconium is a sticky substance that becomes the baby's first poop. It can block or irritate the airways, damage lung tissue and prevent oxygen exchange.
Choice D reason:
Acrocyanosis is not a sign of MAS. It is a normal finding in newborns where the hands and feet appear bluish due to immature circulation. It usually resolves within 24 to 48 hours after birth.
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