A nurse is caring for a newborn in the maternity unit
A nurse is assisting in the care of a newborn. Click to highlight the findings that require follow-up. To deselect a finding, click on the finding again.
General: active with strong cry. HEENT: mucous membranes moist. Respiratory: respirations are shallow and irregular. Cardiovascular: S1, S2, no murmur. Musculoskeletal: moves all extremities well and flexed posture. General: active with high-pitched cry. HEENT: mucous membranes moist. Respiratory: respirations are shallow and irregular. Cardiovascular: S1, S2, no murmur. Musculoskeletal: increased muscle tone with tremors noted upon stimulation. Reflexes: positive Babinski, exaggerated Moro, palmar present.
Active with strong cry
Respirations are shallow and irregular
High-pitched cry
Increased muscle tone with tremors noted upon stimulation
Exaggerated Moro reflex
Mucous membranes moist
Correct Answer : B,C,D,E
Choice A rationale: A strong cry in a newborn is a reassuring sign of intact respiratory effort, neurologic function, and overall vitality. It reflects adequate lung expansion, vocal cord function, and central nervous system integrity. In neonatal abstinence syndrome (NAS), a strong cry alone does not indicate distress unless it is high-pitched or persistent. Therefore, this finding does not require follow-up and is consistent with normal neonatal behavior.
Choice B rationale: Shallow and irregular respirations may reflect autonomic instability associated with NAS. Opioid withdrawal affects the brainstem centers regulating respiratory rhythm, leading to inconsistent breathing patterns. This can increase the risk of apnea, desaturation, or feeding difficulties. Normal neonatal respiratory rate ranges from 30 to 60 breaths per minute with periodic breathing, but shallow and irregular patterns in the context of opioid exposure warrant close monitoring and follow-up.
Choice C rationale: A high-pitched cry is a hallmark sign of NAS and indicates central nervous system irritability. It results from increased excitatory neurotransmission and altered pain perception due to opioid withdrawal. This type of cry is often persistent, difficult to console, and reflects heightened neurologic sensitivity. It is distinct from a normal strong cry and requires follow-up to assess severity, initiate scoring protocols, and determine need for pharmacologic or supportive interventions.
Choice D rationale: Increased muscle tone with tremors upon stimulation is a classic manifestation of NAS. Opioid withdrawal disrupts neuromuscular regulation, leading to hypertonia and exaggerated motor responses. Tremors may be spontaneous or stimulus-induced and reflect heightened sympathetic activity. These findings require follow-up to assess withdrawal severity using standardized scoring tools such as the Finnegan scale and to guide management strategies including swaddling, minimizing stimuli, and possible medication.
Choice E rationale: An exaggerated Moro reflex is a sign of central nervous system hyperexcitability, commonly seen in NAS. The Moro reflex is a normal primitive reflex, but when intensified, it reflects neurologic irritability due to withdrawal. This heightened response may interfere with sleep and feeding and contributes to overall distress. Follow-up is needed to monitor progression, evaluate for other neurologic signs, and determine the need for therapeutic interventions.
Choice F rationale: Moist mucous membranes indicate adequate hydration and perfusion. This finding reflects normal fluid balance and is not associated with NAS pathology. It confirms that feeding is sufficient and that there are no signs of dehydration or systemic compromise. Therefore, this finding does not require follow-up and supports stable clinical status in this domain.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","D","E","F"]
Explanation
Choice A rationale
Neonatal hypoglycemia is typically defined as a blood glucose concentration below 40 mg/dL in the first 4 hours of life, or below 45 mg/dL between 4 and 24 hours. Glucose levels of 40 to 45 mg/dL are generally considered the goal range to prevent neurological injury, not the normal lower limit for up to 72 hours post-birth.
Choice B rationale
If a newborn's blood glucose levels remain persistently below 40 mg/dL after initial management (like feeding) or if they develop symptomatic hypoglycemia, intravenous dextrose will be required. A value persistently below 50 mg/dL is concerning, but the 40 mg/dL threshold is often the critical point for initiating IV glucose when oral methods fail.
Choice C rationale
The umbilical cord provides the fetus with a continuous supply of glucose via the placenta from the mother. Upon umbilical cord clamping, this maternal glucose supply is abruptly interrupted, requiring the newborn's immature metabolic systems to take over glucose homeostasis. This sudden loss of exogenous glucose is a primary factor in transient newborn hypoglycemia.
Choice D rationale
Frequent breastfeeding provides the newborn with a readily available source of lactose, which is metabolized into glucose, thereby promoting the stability of their blood glucose levels. Early and frequent feeding is the primary intervention for transient hypoglycemia in newborns who are able to feed, utilizing the oral route for caloric intake.
Choice E rationale
Transient hypoglycemia is a common and expected physiological adaptation in term newborns during the initial hours after birth. The abrupt cessation of maternal glucose supply necessitates the newborn's activation of gluconeogenesis and glycogenolysis, which may temporarily be insufficient, leading to a mild, self-limiting drop in blood glucose.
Choice F rationale
Skin-to-skin contact immediately after birth is vital as it prevents cold stress. When a newborn is cold, they must expend energy (calories) to produce heat, which consumes glucose, potentially leading to or exacerbating hypoglycemia. Thermoregulation thus indirectly stabilizes blood glucose levels by conserving energy.
Correct Answer is A
Explanation
Choice A rationale
A nonstress test (NST) is a non-invasive prenatal test that monitors the fetal heart rate (FHR) in response to fetal movement. Accelerations of the FHR (increase of ≥ 15 beats per minute lasting ≥ 15 seconds) with movement over 20 minutes (reactive NST) indicate an intact fetal central nervous system and well-oxygenated fetus.
Choice B rationale
A typical NST usually takes about 20 to 40 minutes to complete. A prolonged duration of 2 to 4 hours is usually not necessary unless the fetus is initially inactive, requiring stimulation or extended monitoring to obtain a conclusive tracing. This duration suggests a misunderstanding of the expected procedure length.
Choice C rationale
An NST is generally performed for pregnancies deemed high-risk (e.g., post-dates, diabetes, hypertension, decreased fetal movement), not simply because it is the client's first pregnancy (primigravida). This statement indicates a misconception about the clinical indication for undergoing this specific fetal surveillance test.
Choice D rationale
The primary purpose of an NST is to assess fetal heart rate reactivity; it does not measure the strength or intensity of uterine contractions. Uterine contractions are measured by the tocodynamometer but their strength would be assessed using an internal uterine pressure catheter, which is not part of the standard NST procedure.
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