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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.).

Blood pressure.

Gastrointestinal disturbances.

Skin color.

NAS score.

Temperature.

Oxygen saturation.

Central nervous system disturbances.

Answer and Explanation

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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Correct Answer is D

Explanation

Choice A reason:

Scant scalp hair is not an expected finding for a newborn who is post-term. Scant scalp hair is more common in preterm infants who have not developed fully.

Choice B reason:

Copious vernix is not an expected finding for a newborn who is post-term. Vernix is a white, cheesy substance that covers the skin of the fetus and protects it from the amniotic fluid. Vernix is usually abundant in preterm infants and decreases as gestation progresses.

Choice C reason:

Increased subcutaneous fat is not an expected finding for a newborn who is post-term. Increased subcutaneous fat is a sign of adequate nutrition and growth, which is more likely in term infants. Post-term infants may have reduced subcutaneous fat due to placental insufficiency and decreased nutrient supply.

Choice D reason:

Dry, cracked skin is an expected finding for a newborn who is post-term. Dry, cracked skin is a result of prolonged exposure to the amniotic fluid, which causes dehydration and desquamation of the skin. Post-term infants may also have meconium staining on their skin due to fetal distress.

A. Obesity B. Diabetes insipidus C. Respiratory distress D. Cognitive impairment

Correct Answer is D

Explanation

Choice A reason:

Obesity is not a common complication of phenylketonuria (PKU), a genetic disorder that causes increased levels of phenylalanine (an amino acid) in the body. Obesity may be related to other endocrine disorders, such as hypothyroidism or Cushing syndrome.

Choice B reason:

Diabetes insipidus is a condition that causes excessive thirst and urination due to a lack of antidiuretic hormone (ADH) or a problem with the kidneys' response to ADH. It is not caused by PKU, which affects the metabolism of phenylalanine.

Choice C reason:

Respiratory distress is not a typical symptom of PKU, although some newborns with PKU may have a musty odor in their breath, skin, or urine due to the buildup of phenylalanine.

Respiratory distress may be caused by other conditions, such as asthma, pneumonia, or congenital heart defects.

Choice D reason:

Cognitive impairment is the most serious complication of PKU if it is not diagnosed and treated early. High levels of phenylalanine can damage the brain and cause irreversible intellectual disability, neurological problems, and behavioral issues. Early intervention with a special diet that limits phenylalanine intake can prevent or reduce cognitive impairment in children with PKU.

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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.).

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Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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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.).