A nurse is caring for a newborn who was born at 37 weeks of gestation and is 12 hours old.
Complete the diagram by dragging from the choices below to specify what condition the newborn is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the newborn's progress.
The Correct Answer is []
The diagram should be completed as follows:
Condition Most Likely Experiencing: B. Respiratory distress syndrome. Action to Take 1: C. Administer Surfactant as prescribed. Action to Take 2: Provide oxygen therapy as needed. Parameter to Monitor 1: B. Arterial blood gases. Parameter to Monitor 2: D. Oxygen saturation.
Conditions Explained
Choice A reason:
Hypoglycemia is a condition where the blood glucose level is too low. It can cause symptoms
such as jitteriness, lethargy, poor feeding, and seizures. However, hypoglycemia does not
explain the respiratory signs that the newborn is experiencing, such as tachypnea, grunting,
nasal flaring, and retractions. Acrocyanosis is also not a sign of hypoglycemia. Therefore,
choice A is incorrect.
Choice B reason:
Respiratory distress syndrome (RDS) is a condition where the lungs are not fully developed
and lack enough surfactant, a substance that helps the alveoli stay open and exchange
oxygen and carbon dioxide. It can cause symptoms such as tachypnea, grunting, nasal flaring,
retractions, and cyanosis. RDS is more common in premature infants, especially those born
before 37 weeks of gestation. Acrocyanosis can be a normal finding in the first 24 hours of
life, but it can also indicate poor perfusion due to respiratory compromise. Therefore, choice
B is the most likely condition that the newborn is experiencing.
Choice C reason:
Neonatal abstinence syndrome (NAS) is a condition where the newborn withdraws from
drugs that were exposed in utero. It can cause symptoms such as irritability, tremors, high-
pitched crying, poor feeding, vomiting, diarrhea, and sweating. However, NAS does not
explain the respiratory signs that the newborn is experiencing, such as tachypnea, grunting,
nasal flaring, and retractions. Acrocyanosis is also not a sign of NAS. Therefore, choice C is
incorrect.
Choice D reason:
Jaundice is a condition where the skin and sclerae turn yellow due to excess bilirubin in the
blood. It can be caused by various factors such as blood group incompatibility, hemolysis,
infection, or liver dysfunction. However, jaundice does not explain the respiratory signs that
the newborn is experiencing, such as tachypnea, grunting, nasal flaring, and retractions.
Acrocyanosis is also not a sign of jaundice.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Nalbuphine (Nubain):Nalbuphine is an opioid agonist-antagonist, which can be used to treat moderate to severe pain. However, it is not specifically used to reverse the effects of fentanyl. Administering Nalbuphine could potentially complicate the situation by introducing another opioid into the system.
B. Naloxone (Narcan):Naloxone is an opioid antagonist that rapidly reverses the effects of opioids like fentanyl. It is the standard treatment for opioid overdose and can quickly restore normal respiration in a person whose breathing has slowed or stopped due to opioid use. This makes it the most appropriate drug to have readily available in this scenario.
C. Butorphanol (Stadol):Butorphanol is another opioid agonist-antagonist used for pain relief. Similar to Nalbuphine, it is not used to reverse opioid effects and could complicate the patient's condition by adding another opioid to the system.
D. Promethazine (Phenergan):Promethazine is an antihistamine used to treat nausea, vomiting, and allergies. It does not have any properties that would counteract the effects of fentanyl. Therefore, it would not be useful in reversing opioid-induced respiratory depression.
Correct Answer is D
Explanation
Choice A reason:
The woman in early labor with contractions every 5 minutes lasting 40 seconds each does not require the immediate discontinuation of the oxytocin (Pitocin) infusion. Early labor is characterized by mild and infrequent contractions as the cervix begins to dilate and efface. Choice B reason:
The woman in active labor with contractions every 30 minutes lasting 60 seconds each also does not warrant immediate discontinuation of the oxytocin (Pitocin) infusion. Active labor typically involves regular and stronger contractions as the cervix continues to dilate and the baby progresses downward.
Choice C reason:
The woman in active labor with contractions every 2 to 3 minutes lasting 70 to 80 seconds each does not require immediate cessation of the oxytocin (Pitocin) infusion. These contractions are within the expected range for active labor and may be considered normal.
Choice D reason:
The woman in transition with contractions every 1.5 minutes lasting 95 seconds each should have the oxytocin (Pitocin) infusion discontinued immediately. Transition is the most intense phase of labor, characterized by rapid and strong contractions as the cervix completes dilation. Prolonged and frequent contractions during this phase can lead to uterine hyperstimulation, which can compromise fetal oxygenation and result in fetal distress. Discontinuing the oxytocin infusion is necessary to reduce the intensity and frequency of contractions, ensuring better fetal well-being during this critical phase of labor.
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