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 A
Explanation
Choice A rationale
Oral contraceptives (OCs), particularly combined estrogen-progestin pills, have been scientifically demonstrated to provide a protective effect against the development of both endometrial and ovarian cancers. This effect is thought to be mediated by the suppression of ovulation and reduction in the monthly exposure of the endometrium to unopposed estrogen, thereby modulating cellular proliferation and differentiation within the reproductive tract.
Choice B rationale
Combined estrogen-progestin contraceptive pills typically cause shorter, lighter periods (often referred to as withdrawal bleeding or scheduled bleeding) due to the suppression of endometrial proliferation. The progestin component induces a thin, atrophic endometrium that results in less tissue to shed each month, a benefit for clients experiencing menorrhagia or dysmenorrhea.
Choice C rationale
Medroxyprogesterone acetate (Depo-Provera) is an injectable contraceptive that is administered intramuscularly or subcutaneously. It is designed to provide effective contraception for a duration of three months, requiring the client to receive an injection once every 12 to 13 weeks, not once per month. This prolonged action is due to the slow release and metabolism of the progestin compound.
Choice D rationale
A diaphragm, a barrier method of contraception, is typically made of latex or silicone and needs to be replaced under two primary conditions: significant weight change (gain or loss of 10 pounds or more) or after a full-term pregnancy, as the size and shape of the cervix and vagina may change. Routine replacement due to material degradation is typically advised only every one to two years, not every four years, and only if material integrity is compromised.
Correct Answer is A
Explanation
Choice A rationale
The vagina is approximately 9-10 cm long, angled posterosuperiorly, therefore inserting the suppository along the posterior vaginal wall allows it to follow the natural curve and reach the maximum depth, promoting optimal absorption and therapeutic effect against the localized candidal infection. This positioning ensures the medication remains in contact with the vaginal mucosa for the duration required. The normal vaginal pH is slightly acidic, ranging from 3.8 to 4.5.
Choice B rationale
The supine position with knees flexed, or the Sims' position (lateral with upper leg flexed), is preferred for vaginal insertion as it promotes relaxation of the perineal muscles, facilitating easier and less painful insertion. The prone position is contraindicated because it increases intra-abdominal pressure and makes accessing the vaginal opening difficult, hindering proper placement of the suppository.
Choice C rationale
Water-soluble lubricant, not petroleum jelly, should be applied to the suppository or the gloved finger to reduce friction and minimize irritation during insertion. Petroleum jelly is an oil-based product that can break down the latex in some gloves or condoms and is not easily absorbed, potentially interfering with the medication's dissolution and absorption rate.
Choice D rationale
The suppository should be inserted approximately 7.5 to 10 cm (3 to 4 inches) into the vaginal canal, aiming for the posterior fornix, to ensure it rests deep within the vagina. Inserting only 5 cm (2 inches) is insufficient, as the suppository may be expelled or not reach the areas of the vaginal mucosa necessary for effective systemic or local antifungal treatment.
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