A nurse is assisting in the care of a newborn who is 72 hr 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.
Correct Answer : B,D,F,H
Choice A reason
Blood pressure is not a priority finding for a newborn with neonatal abstinence syndrome (NAS). Blood pressure is usually normal or slightly elevated in NAS, and it is not a reliable indicator of the severity of withdrawal symptoms.
Choice B reason
Gastrointestinal disturbances are a common and serious finding for a newborn with NAS. Vomiting and diarrhea can lead to dehydration, electrolyte imbalance, and poor weight gain. Projectile vomiting can also increase the risk of aspiration. This finding requires immediate follow-up and intervention.
Choice C reason
Skin color is not a priority finding for a newborn with NAS. Acrocyanosis (bluish color of the hands and feet) is a normal finding in newborns and does not indicate hypoxia or poor circulation. It usually resolves within the first few days of life.
Choice D reason
NAS score is not 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. It is based on a set of clinical signs and symptoms that are scored at regular intervals. However, it is not a substitute for clinical judgment and individualized care. The NAS score alone does not determine the urgency of follow-up.
Choice E reason
Temperature is not a priority finding for a newborn with NAS. Temperature may be slightly elevated or normal in NAS, and it is not a specific sign of infection or withdrawal. Temperature regulation is important for newborns, but it is not an immediate concern in this case.
Choice F reason
Oxygen saturation is a priority finding for a newborn with NAS. Tachypnea (rapid breathing) and retractions (inward movement of the chest wall) are signs of respiratory distress, which can compromise oxygen delivery to the tissues and organs. Hypoxia (low oxygen level) can cause brain damage, organ failure, and death if not corrected promptly. This finding requires immediate follow-up and intervention.
Choice G reason
Central nervous system disturbances are a priority finding for a newborn with NAS. Increased muscle tone, tremors, high-pitched cry, and seizures are signs of neurological dysfunction,which can indicate brain injury, bleeding, or infection. Seizures can also worsen hypoxia and metabolic acidosis. This finding requires immediate follow-up and intervention.
Choice H reason
Respiratory rate is not a priority finding for a newborn with NAS. Respiratory rate may be increased or normal in NAS, and it is not a specific sign of respiratory distress or infection. Respiratory rate should be monitored along with other vital signs.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason:
Determining maternal well-being is not the purpose of the Bishop's score. The Bishop's score is a pre-labor scoring system to assist in predicting whether induction of labor will be required. It does not measure maternal vital signs, blood tests, or other indicators of maternal well-being.
Choice B reason:
Determining the readiness of the cervix for labor is the purpose of the Bishop's score. The Bishop's score gives points to five measurements of the pelvic examination: dilation, effacement, station, consistency, and position of the cervix. The higher the score, the more favorable or "ripe”. the cervix is for induction of labor.
Choice C reason:
Determining the progress of labor is not the purpose of the Bishop's score. The Bishop's score is used before labor begins to assess the likelihood of a successful induction or a spontaneous preterm delivery. It does not measure contractions, fetal descent, or other indicators of labor progress.
Choice D reason:
Determining the well-being of the fetus is not the purpose of the Bishop's score. The Bishop's score is a cervical assessment tool that does not directly evaluate fetal status. It does not measure fetal heart rate, movement, or biophysical profile.
Correct Answer is C
Explanation
Choice A reason:
This statement is not appropriate because it does not provide any information or education to the client who wants to know about VBAC. It also implies that the nurse does not have any knowledge or expertise on the topic, which may undermine the client's trust and confidence in the nurse.
Choice B reason:
This statement is not appropriate because it is not evidence-based and may discourage the client from considering VBAC as a possible option. According to research, VBAC is associated with fewer complications than an elective repeat C-section for many women who had prior
cesarean deliveries. A repeat C-section also carries risks such as infection, bleeding, injury to organs, and placental problems in future pregnancies.
Choice C reason:
This statement is appropriate because it is accurate and informative. The type of uterine incision used for the prior C-section is one of the most important factors that determine the eligibility and success of VBAC. A low transverse or low vertical incision is usually compatible with VBAC, while a high vertical (classical) incision is not recommended due to the risk of uterine rupture.
Choice D reason:
This statement is not appropriate because it dismisses the client's concern and does not address their question. It also implies that the nurse does not respect the client's autonomy and right to make informed decisions about their care. The client may benefit from learning about VBAC early in their pregnancy so that they can weigh the pros and cons and discuss their preferences with their provider.
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