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

Physical Examination

  • High-pitched cry
  • Mild tremors when disturbed Increased muscle tone Sneezing six times within 1 hr Excessive sucking
  • Color: Consistent with genetic background Excoriation of the chin
  • Watery stools Projectile vomiting
  • Hyperactive Moro reflex

The nurse is 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.

A.

Regurgitation

B.

Mottling

C.

Transient strabismus

D.

Continuous high-pitched cry

E.

Respiratory rate 70/min

F.

Loose stools

Answer and Explanation

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

Regurgitation: Sign of Potential Worsening Condition - Regurgitation may indicate a feeding problem or gastrointestinal issue, which could worsen if not addressed.

Mottling: Sign of Potential Worsening Condition - Mottling can be a sign of poor perfusion or circulation, indicating potential worsening of the newborn's condition.

 

Transient strabismus: Sign of Potential Improvement - Transient strabismus, or crossed eyes, is common in newborns and often resolves on its own, indicating potential improvement.

Continuous high-pitched cry: Sign of Potential Worsening Condition - Continuous high- pitched crying may indicate discomfort or underlying pathology, suggesting potential worsening. Respiratory rate 70/min: Sign of Potential Worsening Condition - An increased respiratory rate may indicate respiratory distress or another issue, suggesting potential worsening.

Loose stools: Sign of Potential Worsening Condition - Loose stools in a newborn can be a sign of gastrointestinal upset or infection, indicating potential worsening of the newborn's condition.


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Related Questions

Correct Answer is D

Explanation

Rationale:

A. Tubal ligation does not typically affect the length of menstrual periods.

B. While tubal ligation may prevent pregnancy, it does not directly impact premenstrual tension.

C. Hormone replacement therapy is not typically indicated following tubal ligation unless there are other underlying medical reasons for hormone imbalance.

D. "Ovulation will remain the same" is correct. Tubal ligation prevents pregnancy by blocking the fallopian tubes, but it does not affect ovulation. Therefore, the client will continue to ovulate normally after the procedure.

Correct Answer is A

Explanation

A.

Rationale:

A. Breast tenderness:

Correct answer. Clomiphene citrate, a medication used to induce ovulation, can cause breast tenderness as a common adverse effect due to its estrogenic effects.

B. Chills: Chills are not a common adverse effect of clomiphene citrate.

C. Tinnitus: Tinnitus, or ringing in the ears, is not typically associated with clomiphene citrate use.

D. Urinary frequency: Urinary frequency is not a common adverse effect of clomiphene citrate.

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