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A nurse is caring for a newborn.

Exhibits

Drag words from the choices below to fill in each blank in the following sentence. The client is at risk for developing 

and
Answer and Explanation

The Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"D"}

The client is at risk for developing transient tachypnea of the newborn and hypoglycemia.

Rationale

Target 1: Transient Tachypnea of the Newborn (TTN)

  • Transient tachypnea of the newborn (TTN) is a condition characterized by rapid breathing (tachypnea) in the first few hours after birth, typically caused by delayed clearance of fetal lung fluid. It often resolves within 24-48 hours.
  • The newborn in the exhibit has a respiratory rate that is increasing: at 64 minutes, the rate is 68/min, and it increases to 76/min by 0700. This is significantly higher than the normal respiratory rate for a newborn (30-60/min) and is a key sign of tachypnea.
  • Given the increased respiratory rate and the newborn’s age, transient tachypnea of the newborn is a likely concern. This condition is particularly common in late preterm and full-term infants who experience some delay in clearing fetal lung fluid after birth.

Target 2: Hypoglycemia

  • Hypoglycemia in newborns can occur due to several factors, such as increased metabolic demand (which could be indicated by the tachycardia and respiratory rate), poor feeding, or stress during delivery.
  • Tachycardia is one of the early signs of hypoglycemia in newborns, as the body responds to low blood sugar by increasing the heart rate to compensate for the lack of energy.
  • The heart rate is consistently high, with values of 154/min and 156/min during the assessment. This tachycardia could be indicative of hypoglycemia, as the body works harder to compensate for low glucose levels.

Rationale for other conditions;

Bronchopulmonary Syndrome:

This condition refers to lung diseases like bronchopulmonary dysplasia (BPD), which typically occurs in premature infants who have had prolonged mechanical ventilation. There are no signs of this condition in the current assessment, such as the need for respiratory support or signs of chronic lung disease.

The newborn's respiratory rate and tachycardia are more consistent with transient tachypnea rather than a chronic condition like bronchopulmonary syndrome.

Tachycardia:

Tachycardia itself is a symptom, not a diagnosis. The infant's tachycardia could be a response to hypoxia or hypoglycemia, so the condition causing the tachycardia needs to be addressed (which is hypoglycemia and transient tachypnea of the newborn).

 


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Related Questions

Correct Answer is D

Explanation

A. A small fluid deficit of 30 mL is not concerning unless it worsens or additional symptoms develop.
B. Decreased appetite and irritability can be expected with gastroenteritis and may not require immediate intervention.
C. A mild fever and increased pulse rate can be expected, but if these values remain stable and other signs of dehydration or worsening illness are absent, they do not require immediate intervention.
D. Sunken fontanels and dry mucous membranes are signs of dehydration and should be reported to the provider immediately.

Correct Answer is B

Explanation

A. Applying the largest cuff available is important for accurate measurement, but it won’t help with difficulty auscultating sounds.
B. The palpatory method allows the nurse to estimate systolic blood pressure by palpating the pulse while inflating the cuff, which can help avoid difficulties with auscultation.
C. Placing the arm above the level of the heart could result in inaccurate blood pressure readings.
D. Deflating the cuff too quickly can result in inaccurate readings and may also cause discomfort.

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