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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 D

Explanation

Choice A rationale

A Coombs positive result does not necessarily mean that the newborn will require immediate intervention. It indicates that the newborn should be monitored for potential complications such as jaundice and anemia.
Choice B rationale
While the newborn’s glucose level is within the normal range, this does not directly relate to the Coombs positive result.
Choice C rationale
A Coombs positive result may indicate Rh or ABO incompatibility, but this does not directly answer the question of what the nurse should anticipate.
Choice D rationale
This is the correct answer. A Coombs positive result indicates that the newborn should be monitored for signs of jaundice, as this could be a potential complication.

Correct Answer is A

Explanation

Choice A rationale
Facial asymmetry can occur as a result of a forceps-assisted birth. The pressure from the forceps can cause temporary changes in the shape of the baby’s face.
Choice B rationale
Caput succedaneum, a swelling of the scalp in a newborn, is not typically caused by forceps. It is more commonly associated with vacuum extraction.
Choice C rationale
Cephalohematoma, a bleeding underneath one of the cranial bones, is not typically caused by forceps. It is more commonly associated with vacuum extraction.
Choice D rationale

Subgaleal hemorrhage, bleeding into the space between the skull periosteum and the scalp galea aponeurosis, is not typically caused by forceps. It is more commonly associated with vacuum extraction.

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