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.

Regurgitation

Mottling

Transient strabismus

Continuous high-pitched cry

Respiratory rate 70/min

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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Correct Answer is C

Explanation

Rationale:

A. Instructing the client about an autopsy is not the immediate priority and may not be appropriate at this sensitive time.

B. Informing the client about the law regarding naming the fetus is not a priority and may add unnecessary stress to the situation.

C. Providing photos of the fetus is the most appropriate action since it minimzes the trauma to the mother while providing closures.

D. Limiting the amount of time the fetus is in the client's room is not appropriate as when the mother needs more time with the fetus, she hsould be allowed to provide for closure

A. Maintain a low stimulation environment. B. Plan to administer naloxone. C. Instruct the parent to avoid breastfeeding D. Instruct the parent to avoid eye contact with the newborn during feeding E. Perform Ballard newborn screening each shift. F. Weigh the newborn daily. G. Swaddle the newborn with flexed extremities

Correct Answer is ["A","C","E","F","G"]

Explanation

Rationale:

A. Newborns with neonatal abstinence syndrome (NAS) are often irritable and hypersensitive to stimuli. Keeping the environment calm and quiet can help minimize their discomfort.

B. Naloxone is not routinely used in the management of NAS unless there is evidence of severe respiratory depression or opioid overdose, which is not indicated in this scenario.

C. Maternal opioid use and positive urine drug screens for methadone may contraindicate breastfeeding due to the potential transmission of opioids to the infant through breast milk. It's essential to consult with healthcare providers regarding the safest feeding option for the newborn.

D. Eye contact during feeding is essential for bonding between the parent and the newborn and should not be discouraged unless medically necessary.

E. Ballard newborn screening helps assess the newborn's gestational age and guide appropriate care for neonates with NAS, as they may require specialized management.

F. Daily weighing helps monitor the newborn's hydration status and overall well-being, which is crucial in managing NAS and ensuring adequate nutrition.

G. Swaddling can provide comfort to newborns with NAS by mimicking the womb environment and reducing their agitation.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client immediately following the delivery of a stillborn fetus. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

Correct Answer is ["A","C","E","F","G"]

Explanation

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