A nurse is assisting in the care of a newborn who is 72 hr 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.).

Choice A reason:

This statement is incorrect because special lights are used to treat jaundice, not PKU. Jaundice is a condition that causes yellowing of the skin and eyes due to high levels of bilirubin in the blood. Bilirubin is a waste product that is normally removed by the liver. Special lights help break down bilirubin so that it can be excreted from the body.

Choice B reason:

This statement is correct because PKU is a genetic disorder that can be corrected by diet. PKU is caused by a lack of an enzyme that breaks down phenylalanine, an amino acid found in protein-rich foods. Phenylalanine can build up in the blood and cause brain damage and other health problems if not treated. A diet that is low in phenylalanine and high in a special formula can prevent these complications.

Choice C reason:

This statement is correct because sometimes the test is repeated in the doctor's office at the 2-week check-up. The PKU test is done one to three days after birth, but it may not be accurate if the baby has not had enough protein in their diet before the test. A repeat test may be needed to confirm or rule out PKU.

Choice D reason:

This statement is incorrect because the baby must take formula or breast milk after the test is done, not before. The test measures the level of phenylalanine in the blood, which will be higher if the baby has eaten protein-rich foods. The test should be done after the baby has fasted for at least two hours.

Choice A reason:

Injury sustained to the perineum during birth is not a perinatal injury, but a perineal injury. The perineum is the area between the anus and the genitals, and it can be torn or cut during vaginal delivery. This is a common complication that affects the mother, not the fetus or newborn.

Choice B reason:

Traumatic injury to the mother during pregnancy is not a perinatal injury, but a maternal injury. This can occur due to accidents, violence, or complications of pregnancy such as preeclampsia or placental abruption. This can affect the mother's health and well-being, and may also have consequences for the fetus or newborn.

Choice C reason:

Traumatic injury to a fetus is not a perinatal injury, but a fetal injury. This can occur due to external forces such as blunt trauma, penetrating trauma, or radiation exposure that affect the fetus in utero. This can cause fetal distress, bleeding, fractures, or organ damage.

Choice D reason:

Injury sustained surrounding birth is a perinatal injury. This occurs in the period shortly before, during, or after delivery. This can be a critical time when the baby has to transition from surviving off oxygen, blood, and nutrients from the mother to separating from the womb and breathing oxygen from the air. Perinatal injuries can include head injuries, nerve injuries, hemorrhages, fractures, or soft-tissue injuries that result from the forces of labor and delivery or medical interventions such as forceps or vacuum extraction. Perinatal injuries can lead to long-term neurodevelopmental challenges for the newborn.