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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","D"]
Explanation
Choice A rationale
Abdominal distention is not typically associated with hypoglycemia. It can be a sign of other conditions such as gastrointestinal issues.
Choice B rationale
Temperature instability can be a sign of hypoglycemia. Hypoglycemia can interfere with the body’s ability to regulate temperature.
Choice C rationale
Acrocyanosis, or blueness of the skin, is a common finding in newborns and is not typically associated with hypoglycemia.
Choice D rationale
Hypotonia, or decreased muscle tone, can be a sign of hypoglycemia. When blood sugar levels are low, it can affect muscle function.
Correct Answer is D
Explanation
Choice A rationale
Checking the newborn’s identification using the crib card is not the most reliable method. The crib card could be misplaced or switched accidentally.
Choice B rationale
Requiring visitors to wear an identification band does not directly ensure the proper identification of newborns. While it can enhance the security of the unit, it does not link the newborn to their correct parents.
Choice C rationale
Replacing the infant’s identification band after his name has been recorded is not the most effective method. The identification band should be placed on the newborn immediately after birth to prevent mix-ups.
Choice D rationale
Obtaining an imprint of the infant’s feet prior to taking him to the nursery is the correct answer. This method is a reliable way to identify newborns. The footprints, along with the mother’s fingerprints, are often taken within the first hour after birth. This can be used for identification throughout the hospital stay.
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