A nurse is caring for a newborn who is 4 hours old. After reviewing the information in the newborn’s medical record, the nurse should recognize that the newborn is at risk for developing which of the following complications?
The newborn is at risk for developing neonatal abstinence syndrome as evidenced by the urine toxicology screen results.
The newborn is at risk for developing neonatal jaundice as evidenced by the yellowish skin tone.
The newborn is at risk for developing neonatal hypoglycemia as evidenced by the low birth weight.
The newborn is at risk for developing neonatal sepsis as evidenced by the maternal history of infection.
The newborn is at risk for developing neonatal sepsis as evidenced by the maternal history of infection.
The Correct Answer is C
Choice A rationale
Neonatal abstinence syndrome is a condition that results from withdrawal from exposure to narcotics. It is not related to the newborn’s weight.
Choice B rationale
While a yellowish skin tone may indicate jaundice, this is not directly related to the newborn’s weight. Jaundice is caused by an excess of bilirubin, a yellow-orange substance in the blood.
Choice C rationale
Newborns with low birth weight are at risk for hypoglycemia because they have less stored glycogen. They may use up their glucose stores quickly and not have enough intake to maintain their blood glucose levels.
Choice D rationale
Neonatal sepsis is a severe infection in an infant less than 28 days old. It is not directly related to the newborn’s weight but can be associated with maternal infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
If a client reports feeling down and sad, having no energy, and wanting to cry, the nurse’s priority action should be to ask the client if she has considered harming her newborn. This is because these symptoms may indicate postpartum depression, a serious condition that can lead to harm to both the mother and the baby if left untreated.
Choice B rationale
While reinforcing postpartum and newborn care discharge teaching is important, it is not the priority action in this situation. The client’s emotional health needs to be addressed first.
Choice C rationale
Assisting the family to identify prior use of positive coping skills in family crises can be helpful, but it is not the priority action in this situation. The client’s immediate emotional health needs to be addressed first.
Choice D rationale
Anticipating a prescription by the provider for an antidepressant may be part of the treatment plan for this client, but it is not the priority action. The nurse first needs to assess the safety of the client and her newborn.
Correct Answer is C
Explanation
The correct answer is Choice C.
Choice A rationale: A respiratory rate of 16/min is within the normal range for an adult and does not indicate immediate concern.
Choice B rationale: A headache can be a symptom of preeclampsia, but it is not as immediate a concern as the other options unless it is severe or accompanied by other symptoms.
Choice C rationale: A urinary output of 40 ml in 2 hours is significantly below the normal range. Oliguria (low urine output) can be a sign of renal impairment and magnesium toxicity, which requires immediate reporting to the healthcare provider.
Choice D rationale: A fetal heart rate of 158/min is within the normal range for a fetus and does not indicate immediate concern.
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