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A nurse is assisting in the care of a newborn who is 72 hours old and is receiving treatment for neonatal abstinence syndrome.

Exhibits

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

Answer and Explanation

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 A

Explanation

Choice A reason:

Expressions of excitement are an expected finding during the taking-in phase of maternal postpartum adjustment. This is the time of reflection for the woman because, within the 2 to 3-day period, the woman is passive and dependent on her healthcare provider or support person with some of the daily tasks and decision-making. The woman prefers to talk about her experiences during labor and birth and also her pregnancy. The taking-in phase provides time for the woman to regain her physical strength and organize her rambling thoughts about her new role.

Choice B reason:

Lack of appetite is not an expected finding during the taking-in phase of maternal postpartum adjustment. The woman is oriented primarily to her own needs and she primarily focuses on sleeping and eating. She may have increased appetite due to the energy expenditure during labor and delivery. Lack of appetite may indicate postpartum depression or other complications.

Choice C reason:

Eagerness to learn newborn care skills is not an expected finding during the taking-in phase of maternal postpartum adjustment. This is more characteristic of the taking-hold phase, which starts 2 to 4 days after delivery. The woman starts to initiate actions on her own and make decisions without relying on others. She starts to focus on the newborn instead of herself and begins to actively participate in newborn care.

Choice D reason:

Focus on the family unit and its members is not an expected finding during the taking-in phase of maternal postpartum adjustment. This is more indicative of the letting-go phase, which occurs when the woman finally accepts her new role and gives up her old role. This is the phase where postpartum depression may set in. Readjustment of the relationship is needed for an easy transition to this phase.

A. A prior vaginal delivery. B. Gestation of 42 weeks. C. Maternal obesity. D. One prior cesarean delivery. E. Macrosomic fetus.

Correct Answer is ["C","E"]

Explanation

Choice A reason:

A prior vaginal delivery is not a contraindication for VBAC. In fact, it is a positive predictor of success for VBAC, as it indicates that the woman has a proven pelvis and can tolerate labor.

Choice B reason:

The gestation of 42 weeks is not a contraindication for VBAC. However, it is associated with an increased risk of stillbirth while awaiting spontaneous labor, which should be balanced against the risks of induction of labor or elective repeat cesarean.

Choice C reason:

Maternal obesity is a relative contraindication for VBAC. It is associated with a lower success rate of VBAC, a higher risk of uterine rupture, and a higher risk of maternal and neonatal complications. The decision to attempt VBAC in obese women should be made on a case-by-case basis by a senior obstetrician.

Choice D reason:

One prior cesarean delivery is not a contraindication for VBAC. Most women who have had one prior lower segment cesarean delivery are eligible for VBAC, as the risk of uterine rupture is low (0.5%) and the success rate is high (72-75%).

Choice E reason:

A macrosomic fetus is a relative contraindication for VBAC. It is associated with a lower success rate of VBAC, a higher risk of uterine rupture, and a higher risk of shoulder dystocia and birth trauma. The decision to attempt VBAC in women with suspected macrosomia should be made on a case-by-case basis by a senior obstetrician.

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A nurse is assisting in the care of a newborn who is 72 hours old and is receiving treatment for neonatal abstinence syndrome. Exhibits Which of the following data collection findings should the nurse identify as requiring immediate follow-up? (Select all that apply.).

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is 12 hours postpartum. The nurse recognizes the client is in the dependent, taking-in phase of maternal postpartum adjustment. Which of the following is an expected finding during this period?

Correct Answer is A

Explanation

Which of the following are contraindications for VBAC? (Select All that Apply.).

Correct Answer is ["C","E"]

Explanation

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A nurse is assisting in the care of a newborn who is 72 hours old and is receiving treatment for neonatal abstinence syndrome.

Exhibits

Which of the following data collection findings should the nurse identify as requiring immediate follow-up? (Select all that apply.).