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 C
Explanation
Choice A reason:
Charting the normal axillary temperature is not the priority in this situation. The infant's temperature is subnormal, indicating hypothermia, which requires immediate intervention.
Choice B reason:
Rechecking the infant's temperature rectally may provide a more accurate reading, but it is not the priority action at this moment. The infant's low temperature indicates the need for immediate warming to prevent further complications.
Choice C reason:
Placing the infant in a radiant warmer is the priority nursing action. The axillary temperature of 35.9°C (96.6°F) is below the normal range for a newborn, which is around 36.5-37.5°C (97.7-99.5°F). Hypothermia in newborns can be dangerous and lead to respiratory distress, metabolic problems, and other complications. A radiant warmer provides a controlled heat source to warm the infant and stabilize their body temperature.
Choice D reason:
Having the mother breastfeed the infant may help provide warmth and comfort, but it is not the priority action. The immediate concern is to raise the infant's body temperature to a safe range using a radiant warmer.
Correct Answer is B
Explanation
Choice A: Change her position to the right side
Changing the mother’s position to the right side can sometimes help improve fetal oxygenation by relieving pressure on the vena cava. However, since the mother is already lying on her left side, which is typically the preferred position to optimize blood flow, changing to the right side may not be as effective .
Choice B: Place a wedge under the left hip
Placing a wedge under the left hip is a common intervention to improve uteroplacental blood flow. This position helps to tilt the uterus off the vena cava, enhancing venous return and improving cardiac output, which can positively affect fetal oxygenation. This is why it is the correct answer.
Choice C: Lower the head of the bed
Lowering the head of the bed can help increase blood flow to the upper body and brain, but it does not specifically address the issue of improving uteroplacental blood flow. This action is less targeted for resolving nonreassuring fetal heart rate patterns.
Choice D: Place the mother in a Trendelenburg position
The Trendelenburg position, where the mother is laid flat on her back with her feet elevated higher than her head, is generally used to treat hypotension or to improve venous return in cases of shock. However, it is not typically recommended for nonreassuring fetal heart rate patterns as it can increase pressure on the diaphragm and reduce respiratory efficiency.
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