A nurse is caring for a newborn who is 4 hours old.
The newborn is lying in a bassinet, lightly swaddled.
The newborn is noted to be jittery with a weak cry when disturbed. Extremities are mottled with acrocyanosis.
Respirations are rapid and unlabored.
What condition is the newborn most likely experiencing? What are two actions the nurse should take to address that condition, and what are two parameters the nurse should monitor to assess the newborn’s progress?
Hypoglycemia
Neonatal Abstinence Syndrome
Cold Stress
Respiratory Distress Syndrome
The Correct Answer is A
Choice A rationale
The newborn’s symptoms of jitteriness, weak cry, mottled extremities with acrocyanosis, and rapid, unlabored respirations are indicative of hypoglycemia. Hypoglycemia in the newborn period can be caused by several factors, including maternal diabetes (gestational or pre- existing), preterm birth, and sepsis. The nurse should take actions to address this condition, such as ensuring the newborn is warm, initiating early feeding to provide the newborn with glucose, and monitoring blood glucose levels.
Choice B rationale
Neonatal Abstinence Syndrome (NAS) is a group of problems that occur in a newborn who was exposed to addictive opiate drugs while in the mother’s womb. NAS can cause a wide range of symptoms such as excessive crying, poor feeding, and seizures. However, the symptoms described in the question are more indicative of hypoglycemia.
Choice C rationale
Cold stress can occur in newborns who are unable to maintain their body temperature within a normal range. While some of the symptoms described, such as mottled skin and acrocyanosis, can occur with cold stress, the presence of jitteriness and a weak cry are more indicative of hypoglycemia.
Choice D rationale
Respiratory Distress Syndrome (RDS) is a common problem in premature babies and is caused by a lack of surfactant in the lungs. While rapid, unlabored respirations can be a sign of RDS, the other symptoms described in the question, such as jitteriness and a weak cry, are not typically associated with RDS2.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Placenta previa is a condition where the placenta partially or completely covers the cervix. Vaginal bleeding, often without pain, is a key symptom and requires immediate medical attention.
Choice B rationale
While a fetal heart rate of 174 bpm is slightly above the normal range (110-160 bpm), it is not the most critical finding in a patient with complete placenta previa.
Choice C rationale
A fundal height of 33 cm at 32 weeks of gestation is within the expected range and does not require immediate follow-up.
Choice D rationale
An abdomen that is soft and non-tender is a normal finding and does not require immediate follow-up.
Correct Answer is C
Explanation
Choice A rationale
While herbal teas can be a part of a healthy diet, there is no scientific evidence to suggest that drinking herbal tea twice daily can improve fertility. Some herbal teas may even contain substances that could potentially harm a developing fetus or interfere with fertility treatments. Therefore, it’s important for individuals trying to conceive to discuss any dietary supplements or herbal remedies with their healthcare provider.
Choice B rationale
Taking daily hot baths is not recommended as a fertility treatment. In fact, frequent hot baths or hot tub use can actually decrease fertility in men by affecting sperm production. For women, there is no evidence to suggest that hot baths can improve fertility.
Choice C rationale
Maintaining a healthy weight can improve fertility in both men and women. Being overweight or underweight can affect hormone production and make it more difficult to conceive.
Therefore, maintaining a healthy weight through a balanced diet and regular physical activity is one of the most effective non-pharmacological treatments for improving fertility.
Choice D rationale
Using a lubricant during intercourse can make sex more comfortable, but some lubricants can actually decrease fertility by affecting sperm motility. If a lubricant is needed, it’s important to choose a product that is labeled as "fertility-friendly"5.
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