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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

Step 1: According to Naegele’s rule, we start with the first day of the last menstrual period, which is June 212.
Step 2: We then subtract three months, which gives us March 212.
Step 3: Finally, we add seven days, which gives us March 282. So, the estimated date of delivery in the next year is March 28.

Correct Answer is B

Explanation

Choice A rationale
The indirect Coombs test does not determine if a baby is at risk for developing hypoglycemia after birth. It is used to screen for Rh incompatibility.
Choice B rationale
The indirect Coombs test is used to detect the presence of Rh-positive antibodies in your blood. This is particularly important in pregnancy as it can indicate a risk of Rh incompatibility.
Choice C rationale

The indirect Coombs test does not determine the amount of amniotic fluid around the fetus.
Choice D rationale
The indirect Coombs test does not assess blood flow to the fetus and placenta using ultrasound.

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