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 F

Explanation

Choice A rationale

Abnormal stool patterns can be a sign of various issues in newborns, but they do not align with the vital signs presented. The vital signs suggest a more systemic issue rather than one isolated to digestive patterns.

Choice B rationale

While temperature regulation is critical in newborns, especially those who are preterm, the vital signs presented suggest a broader systemic issue. The symptoms do not align with isolated temperature dysregulation.

Choice C rationale

Feeding difficulties can be a sign of neonatal abstinence syndrome but are not directly reflected in the vital signs presented. Neonatal Abstinence Syndrome (NAS) encompasses a range of withdrawal symptoms due to exposure to drugs in utero, not just feeding issues.

Choice D rationale

While extremity issues can be present in various neonatal conditions, they do not align with the systemic symptoms shown in the vital signs. NAS impacts multiple body systems and would present more generalized symptoms.

Choice E rationale

Hypoglycemia can present with some of these vital signs, such as a rapid heart rate, but it does not explain all the symptoms like increased respiratory rate and temperature dysregulation. It is a condition that requires monitoring but is not the primary diagnosis suggested here.

Choice F rationale

Neonatal Abstinence Syndrome is consistent with the vital signs: elevated heart rate, increased respiratory rate, and lower temperature. NAS results from withdrawal from substances the newborn was exposed to in utero and affects multiple body systems, explaining the range of symptoms.

A. Insert a Foley catheter. B. Instruct the client on using a Sitz Bath when she voids. C. Monitor the fundal height. D. Apply a heating pad to the area.

Correct Answer is A

Explanation

Choice A rationale

Inserting a Foley catheter can relieve the bladder and provide an opportunity to monitor urinary output, which is essential for assessing the patient's condition with a perineal hematoma.

Choice B rationale

A Sitz bath may help with pain relief and hygiene but does not address the immediate concern of urinary retention and assessment for injury.

Choice C rationale

Monitoring the fundal height is important but does not address the urgent need to relieve the patient's inability to urinate.

Choice D rationale

Applying a heating pad to the area may help with pain, but it does not address the immediate problem of urinary retention due to the hematoma.

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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

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Correct Answer is F

Explanation

Correct Answer is A

Explanation

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A nurse is caring for a newborn who is 56 hours old.Vital signs at 0700: Heart rate 168/min, Respiratory rate 70/min, Temperature 36.1°C (97.0°F), Oxygen saturation 97%. The nurse reviews the assessment findings and determines the findings are consistent with which of the following complications?

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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.