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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":"D","dropdown-group-2":"A"}

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

Rationale:

Target 1: Transient Tachypnea of the Newborn (TTN): The newborn has progressively increasing respiratory rates (68 → 72 → 76 breaths/min) along with grunting and mild intercostal retractions. Cesarean birth is a major risk factor for TTN because the absence of labor contractions delays the clearance of fetal lung fluid. TTN typically presents within the first few hours of life with tachypnea and mild respiratory distress, resolving within 24–72 hours.

Target 2: Hypoglycemia: The newborn weighs 4200 g (9 lb 4 oz), indicating macrosomia.

Large-for-gestational-age (LGA) infants are at higher risk for hypoglycemia due to increased insulin production in response to maternal hyperglycemia. Tachypnea can also be a sign of hypoglycemia in neonates.

Incorrect Options:

Tachycardia: The newborn’s heart rate is elevated (154–156 bpm), but mild tachycardia is expected in newborns and is not the primary concern compared to respiratory distress and hypoglycemia risk.

Bronchopulmonary Dysplasia (BPD): BPD is a chronic lung condition primarily seen in preterm infants who require prolonged mechanical ventilation and oxygen therapy. This newborn was term, had clear amniotic fluid, and no intubation, making BPD unlikely.


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Related Questions

Correct Answer is D

Explanation

A. Incorrect – Withdrawing TV privileges as a consequence is punitive and not appropriate for managing mania.
B. Incorrect – The dayroom can be overstimulating, worsening manic symptoms. A quiet, structured environment is preferred.
C. Incorrect – Seclusion is only used for severe agitation or if the client poses a danger to themselves or others, not just for anxiety.
D. Correct – Clients experiencing mania have high energy levels and may become exhausted. Encouraging frequent rest helps prevent fatigue and physical depletion.

Correct Answer is A

Explanation

A. APs can remind clients to use the incentive spirometer as part of their role in promoting basic care and client independence.
B. Observing the position of the suspended weight is a nursing responsibility because improper traction can lead to complications.
C. Asking the client to describe their pain requires assessment, which is outside the scope of an AP’s role.
D. Checking the pedal pulse is an assessment task that requires nursing judgment and should not be delegated to an AP.

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