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?
Stools.
Temperature.
Feeding.
Extremities.
Hypoglycemia.
Neonatal Abstinence Syndrome.
The Correct Answer is F
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Docusate sodium is a stool softener and is not contraindicated for a postpartum client with a 4th degree laceration.
Choice B rationale
Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) that can be safely used postpartum for pain management.
Choice C rationale
Carboprost is a medication used to control postpartum hemorrhage but is contraindicated in clients with asthma and with other risk factors due to its side effects, including severe diarrhea.
Choice D rationale
Ferrous sulfate is used to treat anemia and is not contraindicated in a postpartum client with a 4th degree laceration.
Correct Answer is D
Explanation
Choice A rationale
Simply reassuring the parents does not provide them with actions they can take to support their baby's care. While reassurance is important, it must be paired with practical advice that empowers the parents and involves them in the baby's care.
Choice B rationale
Discharge teaching on SIDS prevention is essential but is premature for parents with a 24-week preemie in NICU. The immediate focus should be on supporting them with current care practices and preparing them for future involvement in their baby's daily needs.
Choice C rationale
Discussing diapering, skin, and umbilical cord care is important, but it is not the immediate priority in the NICU context. Parents need guidance on how to support their baby’s current complex care needs rather than routine newborn care at this stage.
Choice D rationale
Emphasizing the importance of pumping breast milk is the most appropriate action. Breast milk is crucial for the baby's nutrition and immune support once enteral feedings begin. This action empowers the parents to actively contribute to their baby's care and prepares for future needs. .
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