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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Related Questions
Correct Answer is ["A","C","D","E"]
Explanation
Choice A reason:
Cerebral palsy is a disorder that affects movement, posture, and muscle tone. It can be caused by brain damage that occurs before, during, or after birth. Premature babies are at a higher risk of developing cerebral palsy because they are more likely to have bleeding in the brain, lack of oxygen to the brain, infections or other complications that can damage the brain.
Choice B reason:
Color blindness is a condition that affects the ability to see colors or differences in colors. It is usually inherited and not related to prematurity. However, some premature babies may develop retinopathy of prematurity, which can affect their vision in other ways.
Choice C reason:
Learning disabilities are problems that affect the ability to learn, read, write, speak or do math. They can be caused by genetic factors, environmental factors or brain injuries.
Premature babies are more likely to have learning disabilities because they are more likely to have brain damage, low birth weight, infections or other complications that can affect their brain development.
Choice D reason:
Retinopathy is a disease that affects the blood vessels in the retina, the light-sensitive layer of tissue at the back of the eye. Retinopathy of prematurity is a condition that occurs when the blood vessels in the retina grow abnormally in premature babies. This can cause bleeding, scarring or detachment of the retina, which can lead to vision loss or blindness.
Choice E reason:
Apnea is a condition that causes pauses in breathing during sleep. Apnea of prematurity is a condition that affects premature babies who have not fully developed their nervous system and respiratory system. This can cause them to stop breathing for more than 20 seconds at a time, which can lower their oxygen levels and heart rate.
Correct Answer is A
Explanation
Choice A reason:
Eating leafy green vegetables is a good way to increase iron intake, as they are rich in iron and other nutrients. Iron is needed to produce hemoglobin, the protein that carries oxygen in red blood cells. Iron deficiency anemia occurs when there is not enough iron to make hemoglobin, resulting in low red blood cell count and low oxygen delivery to the tissues.
Leafy green vegetables such as broccoli, kale, turnip greens, and collard greens are among the best sources of iron from plants.
Choice B reason:
Taking calcium supplements is not helpful for iron deficiency anemia, as calcium can interfere with iron absorption. Calcium binds to iron in the intestine and prevents it from being absorbed into the bloodstream. Therefore, calcium supplements should not be taken at the same time as iron supplements or iron-rich foods. Calcium is important for bone health, but it does not affect hemoglobin production or red blood cell count.
Choice C reason:
Consuming two glasses of prune juice daily is not advisable for iron deficiency anemia, as prune juice has a laxative effect and can cause diarrhea. Diarrhea can lead to dehydration and loss of nutrients, including iron. Prune juice also contains oxalates, which are compounds that can reduce iron absorption by forming insoluble complexes with iron in the intestine. Prune juice does contain some iron, but not enough to compensate for its negative effects on iron status.
Choice D reason:
Consuming raw sushi is not recommended for iron deficiency anemia, as raw fish can contain parasites or bacteria that can cause infections. Infections can increase inflammation and blood loss, which can worsen iron deficiency anemia. Raw fish also contains phytates, which are substances that can inhibit iron absorption by binding to iron in the intestine. Raw fish does provide some iron, but it is not a reliable or safe source of iron for people with iron deficiency anemia. : Iron deficiency anemia - Diagnosis & treatment - Mayo Clinic. : Iron- Deficiency Anemia - Hematology.org.
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