A nurse is caring for a term newborn who is 48 hr old
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
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. This medication increases cardiac output: Magnesium sulfate does not typically increase cardiac output. Its primary role in the context of preeclampsia is to prevent seizures and manage hypertension.
B. This medication stabilizes the fetal heart rate: While magnesium sulfate can have a relaxing effect on the uterus, which might indirectly influence fetal heart rate, its primary purpose in preeclampsia is seizure prevention rather than fetal heart rate stabilization.
C. The medication improves tissue perfusion: Magnesium sulfate primarily functions as an anticonvulsant and tocolytic (relaxes the uterus). While its effects on vasodilation can contribute to improved blood flow, the primary indication in preeclampsia is seizure prevention.
D. The medication prevents seizures
Magnesium sulfate is commonly used in the management of preeclampsia to prevent seizures (eclampsia), a serious complication of the condition. It has anticonvulsant properties and is the primary medication for seizure prophylaxis in pregnant individuals with preeclampsia.
Correct Answer is B
Explanation
A. Weak cry: A weak cry is not a specific manifestation associated with newborns exposed to methadone. Methadone-exposed newborns may show signs of neonatal abstinence syndrome (NAS), but a weak cry is not a primary characteristic.
B. Poor feeding: This is the correct answer. Poor feeding is a common manifestation of neonatal abstinence syndrome (NAS) in newborns exposed to opioids, including methadone. NAS can cause gastrointestinal symptoms, including feeding difficulties.
C. Respiratory rate of 30/min: While respiratory issues can be part of the neonatal abstinence syndrome, a specific respiratory rate of 30/min is not universally characteristic. NAS symptoms can vary among infants.
D. Absent Moro reflex: The Moro reflex is not typically affected in infants exposed to methadone. NAS symptoms often involve central nervous system irritability, but the Moro reflex is a complex primitive reflex that may remain intact.
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