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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.

A.

Regurgitation

B.

Transient strabismus

C.

Mottling

D.

Respiratory rate 70/min

E.

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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Related Questions

Correct Answer is C

Explanation

Choice A rationale
A urinary output of 300 ml in 8 hours is within the normal range for a postpartum patient. The average urinary output is about 30 ml/hour.
Choice B rationale
Lochia rubra is a normal finding in the immediate postpartum period. It is the initial vaginal discharge after childbirth, which is red because it contains a large amount of blood. Changing perineal pads every 3 hours is considered normal.
Choice C rationale

A patient who is receiving magnesium sulfate and has absent deep tendon reflexes is experiencing magnesium toxicity. This is a serious condition that can lead to respiratory depression and cardiac arrest. The healthcare provider should be notified immediately.
Choice D rationale
Abdominal cramping during breastfeeding is a normal finding. During breastfeeding, the hormone oxytocin is released which can cause uterine contractions and lead to cramping.

Correct Answer is A

Explanation

Choice A rationale
Puncturing the lateral side of the heel is the correct procedure when performing a heel stick on a newborn. This area is less likely to come into contact with hard surfaces that could cause injury to the puncture site.
Choice B rationale
A 21-gauge needle is too large for a heel stick procedure on a newborn. A smaller gauge needle or a lancet is typically used to ensure the puncture is as small and painless as possible.
Choice C rationale
Applying an alcohol pad to the site after the procedure is not recommended. Alcohol can cause skin irritation and dryness. Instead, a sterile gauze or bandage is usually applied to stop any bleeding from the puncture site.
Choice D rationale
Placing a cold cloth at the site for 15 minutes before the procedure is not recommended. Cold can cause vasoconstriction, which would make it more difficult to obtain a blood sample.
Instead, warming the heel prior to the stick can help to increase blood flow to the area.

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