A nurse is caring for a term newborn who is 48 hr old

Exhibits

The nurse assessing the newborn 24 hr later. How should the nurse interpret the findings?

For each finding, click to specify whether the finding is unrelated to the diagnosis, a sign of potential improvement, or a sign of potential worsening condition.

Transient strabismus

Respiratory rate 70/min

Continuous high-pitched cry

Regurgitation

Loose stools

Answer and Explanation

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

Transient strabismus:

Interpretation: Unrelated to diagnosis

Explanation: Transient strabismus (crossed eyes) is not necessarily related to the maternal history of opioid use or precipitous birth. It is a common finding in newborns and often resolves on its own without intervention.

Respiratory rate 70/min:

Interpretation: Sign of potential worsening condition

Explanation: A respiratory rate of 70/min in a newborn is higher than the normal range (30-60 breaths per minute). This could indicate respiratory distress, infection, or other complications, requiring further assessment.

Continuous high-pitched cry:

Interpretation: Sign of potential worsening condition

Explanation: A continuous high-pitched cry can be a sign of potential distress or discomfort in a newborn. It may be associated with various conditions, including withdrawal symptoms related to maternal opioid use during pregnancy. This finding warrants further assessment.

Regurgitation:

Interpretation: Unrelated to diagnosis

Explanation: Regurgitation (spitting up) is a common occurrence in newborns and is not necessarily related to the maternal history of opioid use. It is often a normal physiological process in infants.

Loose stools:

Interpretation: Unrelated to diagnosis

Explanation: Loose stools can be a normal finding in newborns and may not be directly related to the maternal history of opioid use. It is not necessarily indicative of a worsening condition in this context.

Nursing Test Bank

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Correct Answer is B

Explanation

. Protective environment: Protective environment precautions are used for clients with compromised immune systems, such as those undergoing stem cell transplantation. This precaution aims to protect the client from exposure to environmental pathogens.

B. Contact: This is the correct answer. Contact Precautions are appropriate for clients with C. difficile infection. The precautions include using gloves and gowns when entering the room and ensuring proper hand hygiene to prevent the transmission of the bacteria.

C. Droplet: Droplet precautions are used for diseases that are transmitted through respiratory droplets, such as influenza or pertussis. C. difficile is not primarily transmitted through respiratory droplets.

D. Airborne: Airborne precautions are used for diseases that can be transmitted by tiny particles suspended in the air, such as tuberculosis or chickenpox. C. difficile is not transmitted through the airborne route.

A. Administer oxygen via a face mask B. Decrease the rate of IV fluids C. perform fetal scalp stimulation D. Elevate the client’s head

Correct Answer is A

Explanation

A. Administer oxygen via a face mask: This is the correct answer. Administering oxygen helps improve oxygenation to the fetus and is a standard intervention for late decelerations.

B. Decrease the rate of IV fluids: Decreasing IV fluids is not typically the first intervention for late decelerations. The primary goal is to improve oxygenation to the fetus, and increasing or maintaining maternal blood volume is important.

C. Perform fetal scalp stimulation: Fetal scalp stimulation is not the first-line intervention for late decelerations. It is more commonly used for assessing fetal well-being and responsiveness during the labor process.

D. Elevate the client’s head: Elevation of the client's head is not the recommended position for addressing late decelerations. Placing the client in a side-lying position is more appropriate to relieve pressure on the vena cava.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who is at 28 weeks of gestation and has a Clostridium difficile infection. The nurse should initiate which of the following types of isolation precautions for the client?

Correct Answer is B

Explanation

A nurse is caring for a client who is in labor. The nurse observes late decelerations of the fetal heart rate on the external fetal monitor. After placing the client in a side-lying position, which of the following actions should the nurse take?

Correct Answer is A

Explanation

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