A nurse is caring for a newborn.
Drag words from the choices below to fill in each blank in the following sentence.
The client is at risk for developing
The Correct Answer is {"dropdown-group-1":"A","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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Providing humidified air can help relieve the dryness associated with xerostomia (dry mouth).
B. Instructing on esophageal speech is unrelated to managing xerostomia.
C. Offering saltine crackers between meals may worsen dry mouth by stimulating further saliva reduction.
D. Alcohol-based mouthwashes can further dry out the oral mucosa and should be avoided.
Correct Answer is B
Explanation
A. Continuous bladder irrigation is not appropriate unless the client has a condition like post-op bleeding from bladder surgery.
B. Low urine output (oliguria) of <30 mL/hr and dark yellow urine suggest dehydration or decreased kidney perfusion, which can be corrected with IV fluid administration.
C. Clamping the catheter could worsen urinary retention and is not appropriate.
D. A urine culture is needed only if infection is suspected, but this scenario suggests dehydration, not infection.
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