A nurse is caring for a term newborn male client who is 72 hours old in the neonatal intensive care unit. The newborn was born after a precipitous vaginal birth at 39 weeks of gestation. The mother has a history of opioid use during pregnancy.
Exhibits
The nurse is assessing the newborn 24 hours later. For each finding, specify whether the finding is unrelated to the diagnosis, a sign of potential improvement, or a sign of potential worsening condition.

Regurgitation

Transient strabismus

Mottling

Respiratory rate 70/min

Continuous high-pitched cry

Answer and Explanation

The Correct Answer is {"A":{"answers":"C"},"B":{"answers":"A"},"C":{"answers":"C"},"D":{"answers":"C"},"E":{"answers":"C"}}

•   Regurgitation: This could be a sign of potential worsening condition as it might indicate gastrointestinal issues, which can be a symptom of Neonatal Abstinence Syndrome (NAS).
•   Transient strabismus: This is unrelated to the diagnosis. Strabismus is common in newborns and usually resolves on its own within the first few months of life.
•   Mottling: This could be a sign of potential worsening condition. Mottling (a lacy pattern of dilated blood vessels under the skin) can be a sign of distress in a newborn.
•   Respiratory rate 70/min: This could be a sign of potential worsening condition. A respiratory rate of 70/min is higher than the normal range (30-60 breaths per minute) for a newborn, indicating possible respiratory distress.
•   Continuous high-pitched cry: This could be a sign of potential worsening condition. A high-pitched cry is a common symptom of NAS.
•   Loose stools: This could be a sign of potential worsening condition. Loose stools can be a symptom of NAS.

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Correct Answer is D

Explanation

Choice A rationale

Applying hydrating lotion to the newborn’s skin prior to treatment is not recommended. The goal of phototherapy is to expose the newborn’s skin to light, and applying lotion could potentially interfere with the effectiveness of the treatment.
Choice B rationale
Providing the newborn with 15 mL glucose water after each feeding is not a standard part of phototherapy treatment. The newborn should continue to receive regular feedings, but additional glucose water is not typically necessary.
Choice C rationale
Turning the newborn every 4 hours is not sufficient during phototherapy. The newborn should be repositioned frequently, ideally every 2-3 hours, to expose all areas of the skin to the light.
Choice D rationale
It is important to protect the newborn’s eyes during phototherapy to prevent damage from the light. Therefore, the newborn’s eyes should be covered with special patches whenever the lights are on.

A. The client is changing the perineal pad once daily. B. The client cleans the perineum with a squeeze bottle after urinating. C. The client’s perineal suture line is well approximated. D. The client is using witch hazel pads on the perineum.

Correct Answer is A

Explanation

Choice A rationale

Changing the perineal pad only once daily can lead to an increased risk of infection, which can delay wound healing. It’s important to maintain cleanliness in the perineal area, especially after a laceration, to promote healing.
Choice B rationale
Cleaning the perineum with a squeeze bottle after urinating is actually a recommended practice. It helps to keep the area clean and reduce the risk of infection.
Choice C rationale
A well-approximated perineal suture line is a positive sign of healing. It indicates that the edges of the wound are close together, which promotes healing and reduces the risk of infection.
Choice D rationale
Using witch hazel pads on the perineum can provide relief from discomfort and has astringent properties that can promote healing.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a newborn with jaundice who has a new prescription for phototherapy. What actions should the nurse take?

Correct Answer is D

Explanation

A nurse is caring for a client who is postpartum and has a perineal laceration. What findings place the client at risk for delayed wound healing?

Correct Answer is A

Explanation

A nurse manager is revising a policy in the maternal unit to ensure proper identification of newborns. What should the nurse include in the policy?

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