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
Explanation
Choice A reason:
FAS is caused by alcohol, and NAS is caused by opioids. This is the correct answer because FAS stands for fetal alcohol syndrome, which is a group of physical and mental defects that can occur in a baby when a woman drinks alcohol during pregnancy. NAS stands for neonatal abstinence syndrome, which is a group of problems that can happen when a baby is exposed to opioid drugs for a length of time while in their mother's womb.
Choice B reason:
FAS and NAS are both incurable. This is incorrect because FAS and NAS have different outcomes. FAS is incurable because the effects of alcohol on the developing brain and body are permanent. NAS, however, can be treated with medication and supportive care to help the baby cope with withdrawal symptoms and prevent complications.
Choice C reason:
FAS and NAS are both curable. This is incorrect because FAS is not curable, as explained above. NAS can be treated, but not cured, because some babies may have long-term problems such as developmental delays, behavioral issues, or learning difficulties.
Choice D reason:
FAS is caused by analgesics and NAS is caused by NSAIDs. This is incorrect because FAS is caused by alcohol, not analgesics, which are painkillers. NAS is caused by opioids, not NSAIDs, which are anti-inflammatory drugs. Analgesics and NSAIDs do not cause the same type of damage to the fetus or the newborn as alcohol and opioids do.
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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