A nurse is assisting with the care of a newborn who is 4 hours old in the neonatal unit.
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client’s progress.
The Correct Answer is []
Based on the provided information, here’s the completed diagram:
Potential Condition
- Neonatal abstinence syndrome
Actions to Take
- Reinforce with the parent to feed the newborn
- Anticipate a prescription to obtain a capillary blood sample
Parameters to Monitor
- Respiratory status
- Temperature
Congenital Syphilis
- Reasoning: The mother’s syphilis was treated successfully in the first trimester, and her subsequent tests (VDRL and RPR) were negative. This indicates that the infection was resolved, making congenital syphilis unlikely.
Hypoglycemia
- Reasoning: While some symptoms like jitteriness and weak cry could suggest hypoglycemia, the newborn’s weight (4,366 g) and the absence of other typical signs like lethargy or seizures make this less likely. Additionally, there is no mention of a blood glucose test result indicating hypoglycemia.
Kernicterus
- Reasoning: Kernicterus is a severe form of jaundice caused by high bilirubin levels. The newborn’s symptoms (jitteriness, weak cry, mottled extremities, acrocyanosis) do not align with the typical presentation of kernicterus, which includes severe jaundice, lethargy, and high-pitched crying. There is also no mention of elevated bilirubin levels.
Neonatal Abstinence Syndrome (NAS)
- Reasoning: The newborn’s symptoms (jitteriness, weak cry, rapid respirations, restlessness, difficulty feeding, and decreased muscle tone) are consistent with NAS, which can occur due to maternal substance use during pregnancy. The positive urine drug screen for marijuana supports this diagnosis
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Warming the newborn’s heel for 5 to 10 minutes before the puncture increases blood flow, making it easier to collect a blood sample.
Choice B rationale
The outer aspect of the heel is the recommended site for puncture to avoid injury to the bone and nerves.
Choice C rationale
Leaving the heel open to the air after the puncture is not recommended as it can increase the risk of infection.
Choice D rationale
Applying an antiseptic after collecting the specimen is not necessary and can interfere with the blood sample.
Correct Answer is B
Explanation
Choice A rationale
Diazepam is a benzodiazepine used primarily for anxiety, muscle spasms, and seizures. It is not recommended for opioid use disorder during pregnancy due to potential risks to the fetus, including withdrawal symptoms and developmental issues.
Choice B rationale
Methadone is a long-acting opioid agonist used to treat opioid use disorder. It helps reduce withdrawal symptoms and cravings without producing the euphoria associated with opioid abuse. Methadone is considered safe for use during pregnancy and can improve maternal and fetal outcomes.
Choice C rationale
Naloxone is an opioid antagonist used to reverse opioid overdose. While it is crucial to have naloxone readily available for individuals with opioid use disorder to prevent overdose deaths, it is not a primary treatment for opioid use disorder during pregnancy.
Choice D rationale
Buprenorphine is a partial opioid agonist used to treat opioid use disorder. It is considered safe for use during pregnancy and can reduce withdrawal symptoms and cravings. However, methadone is often preferred due to its longer history of use and more extensive research on its safety during pregnancy.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.