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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Related Questions
Correct Answer is A
Explanation
Choice A reason:
Uterine atony is the failure of the uterus to contract and retract after delivery, which can lead to excessive bleeding and hemorrhage. It is the most common cause of postpartum hemorrhage, accounting for up to 80 percent of cases. Risk factors for uterine atony include large or multiple babies, prolonged or rapid labor, overdistended uterus, use of oxytocin or magnesium sulfate during labor, and previous history of uterine atony.
Choice B reason:
Puerperal infection is an infection of the reproductive tract that occurs within six weeks after delivery. It can affect the uterus (endometritis), the bladder (cystitis), the kidneys (pyelonephritis), the breast (mastitis), or the wound (cesarean section or episiotomy).
Symptoms include fever, chills, malaise, foul-smelling lochia, pelvic pain, and wound redness or drainage. Risk factors for puerperal infection include cesarean delivery, prolonged rupture of membranes, prolonged labor, multiple vaginal examinations, retained placental fragments, and poor hygiene.
Choice C reason:
Retained placental fragments are pieces of the placenta that remain in the uterus after delivery. They can cause postpartum hemorrhage, infection, or delayed involution of the uterus. Symptoms include heavy or prolonged bleeding, fever, abdominal pain, and an enlarged uterus. Risk factors for retained placental fragments include placenta previa, placenta accrete, manual removal of the placenta, and incomplete examination of the placenta after delivery.
Choice D reason:
Thrombophlebitis is the inflammation and clotting of a vein, usually in the legs or pelvis. It can cause pain, swelling, redness, and warmth in the affected area. It can also lead to pulmonary embolism if the clot breaks off and travels to the lungs. Risk factors for thrombophlebitis include pregnancy and the postpartum period, cesarean delivery, obesity, smoking, dehydration, immobility, varicose veins, and inherited or acquired clotting disorders.
Correct Answer is ["A","C"]
No explanation
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