A nurse is caring for a newborn who is 56 hours old in the neonatal unit. Below are the exhibits.

Exhibits

A nurse reviews the assessment findings and determines the findings are consistent with which of the following complications? Each finding may support more than one disease process.

Jitteriness

Lethargy

Poor Feeding

Jaundice

Loose Stool

Answer and Explanation

The Correct Answer is {"A":{"answers":"A,C"},"B":{"answers":"A,C"},"C":{"answers":"A,C"},"D":{"answers":"B"},"E":{"answers":"C"}}

Jitteriness: This can be a sign of hypoglycemia in a newborn, and it may also be seen in Neonatal Abstinence Syndrome (NAS) due to withdrawal symptoms.
Lethargy: Lethargy is common in hypoglycemia (due to low energy reserves) and can also be seen in Neonatal Abstinence Syndrome due to withdrawal effects.
Poor Feeding: Hypoglycemia may cause poor feeding due to the lack of energy, and Neonatal Abstinence Syndrome can cause feeding difficulties because of withdrawal symptoms.
Jaundice: Jaundice is a hallmark sign of Neonatal Jaundice, typically due to elevated bilirubin levels.
Loose Stool: Loose stool can be a sign of Neonatal Abstinence Syndrome, as gastrointestinal disturbances are common in withdrawal. It is not typically associated with hypoglycemia or neonatal jaundice.

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Correct Answer is ["A","B","D"]

Explanation

Choice A rationale

A large ecchymotic caput succedaneum, which is swelling of the scalp due to birth trauma, usually resolves within a few days. However, its large size and presence of bruising should be monitored for potential complications such as jaundice.

Choice B rationale

Yellow discoloration of the sclera and oral mucosa indicates jaundice, which can be due to hyperbilirubinemia. This condition requires follow-up and possible treatment to prevent severe complications.

Choice C rationale

A level and soft fontanel in a newborn is a normal finding. It does not require follow-up as it indicates that intracranial pressure is normal.

Choice D rationale

A respiratory rate of 78/min in a newborn is significantly higher than the normal range (30-60/min). This finding requires follow-up to assess for respiratory distress or other underlying conditions.

A. Ask the client if she has considered harming her newborn. B. Anticipate a prescription by the provider for an antidepressant. C. Assist the family to identify prior use of positive coping skills in family crises. D. Reinforce postpartum and newborn care discharge teaching.

Correct Answer is A

Explanation

Choice A rationale

Asking if the client has considered harming her newborn is a priority to assess for potential postpartum depression or psychosis, which require immediate intervention. .

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A nurse is caring for a newborn who is 56 hours old in the neonatal unit. Below are the exhibits. Exhibits A nurse reviews the assessment findings and determines the findings are consistent with which of the following complications? Each finding may support more than one disease process.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a newborn 8 hours of age.Which of the following assessment findings require follow-up by the nurse?

Correct Answer is ["A","B","D"]

Explanation

A nurse in a clinic is caring for a client who is 3 weeks postpartum following the birth of a healthy newborn.The client reports feeling "down" and sad, having no energy, and wanting to cry.Which of the following is a priority action by the nurse?

Correct Answer is A

Explanation

The RN has received a hand-off report.Which client does the RN need to see first?

A certified nursing assistant (CN

The nurse present at the delivery is reporting to the nurse who will be caring for the infant who had thick meconium in the amniotic fluid.

The client has a physician's order for Methylergonovine (Methergine) 0.2 mg by mouth every 6 hours for 24 hours. The RN knows the reason for this order is to assist in controlling postpartum bleeding. What is the total amount the patient will receive in mg in a 24-hour period?

A mother refused to allow her son to receive the phytonadione (Mephyton) injection at birth as was stated on her birth plan.Which of the following signs or symptoms might the nurse observe in the baby as a result?

A nurse is caring for a mother who delivered vaginally 2 hr ago.Heart rate 106/min.Axillary temperature 36.6° C (98.0° F). Respiratory rate 22 /min.Oxygen saturation 94%. Select the 4 findings the nurse should report to the provider.

A nurse is caring for a newborn who is 56 hours old in the neonatal unit. Below are the exhibits.

Exhibits

A nurse reviews the assessment findings and determines the findings are consistent with which of the following complications? Each finding may support more than one disease process.