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.

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Free Nursing Study Resources

Correct Answer is D

Explanation

a.Apply hydrating lotion to the newborn's skin prior to treatment: It is not necessary to apply hydrating lotion before phototherapy. However, keeping the newborn's skin well-moisturized is generally a good practice to prevent dryness associated with phototherapy.

b.Turn the newborn every 4 hours: Regular turning is important for general care, but it is not a specific action related to phototherapy for jaundice.

c.Provide the newborn with 15 ml glucose water after each feeding: This is not a standard practice related to phototherapy. Feeding frequency and amounts are determined by the infant's age, weight, and feeding readiness, but providing glucose water after each feeding is not a routine recommendation

d. Close the newborn's eyes before applying eyepatches: This is the correct answer. Eyepatches are used during phototherapy to protect the newborn's eyes from exposure to the bright lights. Closing the newborn's eyes before applying eyepatches helps shield the eyes from the light source and prevents potential damage to the eyes.

A. Hot flashes B. Heart palpitations C. Shortness of breath D. Bradycardia

Correct Answer is B

Explanation

A. Hot flashes: Hot flashes are not a typical adverse effect of terbutaline. Hot flashes are more commonly associated with hormonal changes, such as those that occur during menopause.

B. Heart palpitations: This is the correct answer. Terbutaline can stimulate beta-2 receptors in the heart, leading to increased heart rate and palpitations. Clients receiving terbutaline should be monitored for cardiac side effects.

C. Shortness of breath: While terbutaline is used to relax smooth muscles, it can also affect beta-2 receptors in the respiratory system. However, shortness of breath is not a common adverse effect and may indicate other respiratory issues.

D. Bradycardia: Bradycardia, or a slow heart rate, is not a typical adverse effect of terbutaline. The medication is more likely to increase heart rate due to its beta-2 adrenergic agonist properties.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a newborn who has jaundice and a new prescription for phototherapy. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is caring for a client who is receiving terbutaline to treat preterm labor. Which of the following findings should the nurse identify as a potential adverse effect of this medication?

Correct Answer is B

Explanation

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