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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?

Stools.

Temperature.

Feeding.

Extremities.

Hypoglycemia.

Neonatal Abstinence Syndrome.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A rationale

A diaphragm must be left in place for at least 6 hours after intercourse to prevent sperm from reaching the uterus. This ensures effective contraception.

Choice B rationale

Depo-Provera is a long-acting contraceptive injection, and fertility can return within a few months after stopping, but it may take up to 9-10 months for some women to regain their regular menstrual cycles and fertility.

Choice C rationale

The Ortho Evra patch is a hormonal contraceptive that is applied weekly, not monthly. It needs to be replaced once a week for three weeks, followed by a patch-free week.

Choice D rationale

Male and female condoms should not be used together because they can create friction and cause either or both condoms to break or slip, reducing their effectiveness as contraceptives and increasing the risk of sexually transmitted infections.

A. "I will try drinking an herbal tea to reduce the engorgement.”. B. "I will apply warm compresses 20 minutes before feeding.”. C. "I will let my baby drain one breast at each feeding.”. D. "I will feed my baby every 3-4 hours.”.

Correct Answer is B

Explanation

Choice A rationale

Herbal tea is not scientifically proven to reduce breast engorgement and may not be effective.

Choice B rationale

Warm compresses applied before feeding help to soften the breasts, making it easier for the baby to latch and reducing engorgement.

Choice C rationale

Letting the baby drain one breast completely at each feeding can help prevent engorgement but is not specifically for managing existing engorgement.

Choice D rationale

Feeding every 3-4 hours may not be frequent enough to prevent engorgement, especially in the early days of breastfeeding.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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