A nurse is explaining TTN to the newborn's mother. Which statement indicates that the mother understands the teaching?

"My baby might be in the NICU for 2 weeks.".

"This breathing problem might have happened because I had a cesarean birth.".

"I cannot breastfeed my baby while he is breathing so fast.".

"My baby will probably go home on oxygen therapy.".

Answer and Explanation

The Correct Answer is B

Choice A reason:

This is incorrect because TTN usually resolves within 24 to 72 hours of birth and does not require a long stay in the NICU.

Choice B reason:

This is correct because TTN is more common in babies born by cesarean section without labor, as they do not have the hormonal changes that help clear the fetal lung fluid.

Choice C reason:

This is incorrect because breastfeeding is not contraindicated in babies with TTN, unless they have severe respiratory distress or need continuous positive airway pressure (CPAP) support.

Choice D reason:

This is incorrect because TTN does not cause chronic lung disease or require oxygen therapy at home. Most babies with TTN only need supplemental oxygen for a few days until their breathing improves.

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Correct Answer is A

Explanation

Choice A reason:

Expressions of excitement are an expected finding during the taking-in phase of maternal postpartum adjustment. This is the time of reflection for the woman because, within the 2 to 3-day period, the woman is passive and dependent on her healthcare provider or support person with some of the daily tasks and decision-making. The woman prefers to talk about her experiences during labor and birth and also her pregnancy. The taking-in phase provides time for the woman to regain her physical strength and organize her rambling thoughts about her new role.

Choice B reason:

Lack of appetite is not an expected finding during the taking-in phase of maternal postpartum adjustment. The woman is oriented primarily to her own needs and she primarily focuses on sleeping and eating. She may have increased appetite due to the energy expenditure during labor and delivery. Lack of appetite may indicate postpartum depression or other complications.

Choice C reason:

Eagerness to learn newborn care skills is not an expected finding during the taking-in phase of maternal postpartum adjustment. This is more characteristic of the taking-hold phase, which starts 2 to 4 days after delivery. The woman starts to initiate actions on her own and make decisions without relying on others. She starts to focus on the newborn instead of herself and begins to actively participate in newborn care.

Choice D reason:

Focus on the family unit and its members is not an expected finding during the taking-in phase of maternal postpartum adjustment. This is more indicative of the letting-go phase, which occurs when the woman finally accepts her new role and gives up her old role. This is the phase where postpartum depression may set in. Readjustment of the relationship is needed for an easy transition to this phase.

A. Blood pressure. B. Gastrointestinal disturbances. C. Skin color. D. NAS score. E. Temperature. F. Oxygen saturation. G. Central nervous system disturbances. H. Respiratory rate.

Correct Answer is ["B","F","G"]

Explanation

Choice A reason:

Blood pressure is not a priority finding for a newborn with neonatal abstinence syndrome (NAS). Blood pressure is usually normal or slightly elevated in NAS, and it is not a reliable indicator of the severity of withdrawal symptoms.

Choice B reason:

Gastrointestinal disturbances are a common and serious finding for a newborn with NAS. Vomiting and diarrhea can lead to dehydration, electrolyte imbalance, and poor weight gain. Projectile vomiting can also increase the risk of aspiration. This finding requires immediate follow-up and intervention.

Choice C reason:

Skin color is not a priority finding for a newborn with NAS. Acrocyanosis (bluish color of the hands and feet) is a normal finding in newborns and does not indicate hypoxia or poor circulation. It usually resolves within the first few days of life.

Choice D reason:

NAS score is not a priority finding for a newborn with NAS. NAS score is a tool used to assess the severity of withdrawal symptoms and the need for pharmacological treatment. It is based on a set of clinical signs and symptoms that are scored at regular intervals. However, it is not a substitute for clinical judgment and individualized care. The NAS score alone does not determine the urgency of follow-up.

Choice E reason:

Temperature is not a priority finding for a newborn with NAS. The temperature may be slightly elevated or normal in NAS, and it is not a specific sign of infection or withdrawal. Temperature regulation is important for newborns, but it is not an immediate concern in this case.

Choice F reason:

Oxygen saturation is a priority finding for a newborn with NAS. Tachypnea (rapid breathing) and retractions (inward movement of the chest wall) are signs of respiratory distress, which can compromise oxygen delivery to the tissues and organs. Hypoxia (low oxygen level) can cause brain damage, organ failure, and death if not corrected promptly. This finding requires immediate follow-up and intervention.

Choice G reason:

Central nervous system disturbances are a priority finding for a newborn with NAS. Increased muscle tone, tremors, high-pitched cries, and seizures are signs of neurological dysfunction, which can indicate brain injury, bleeding, or infection. Seizures can also worsen hypoxia and metabolic acidosis. This finding requires immediate follow-up and intervention.

Choice H reason:

Respiratory rate is not a priority finding for a newborn with NAS. Respiratory rate may be increased or normal in NAS, and it is not a specific sign of respiratory distress or infection. Respiratory rate should be monitored along with other vital signs, but.

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A nurse is explaining TTN to the newborn's mother. Which statement indicates that the mother understands the teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is 12 hours postpartum. The nurse recognizes the client is in the dependent, taking-in phase of maternal postpartum adjustment. Which of the following is an expected finding during this period?

Correct Answer is A

Explanation

A nurse is assisting in the care of a newborn who is 72 hr old and is receiving treatment for neonatal abstinence syndrome. Exhibits Which of the following data collection findings should the nurse identify as requiring immediate follow-up? (Select all that apply.).

Correct Answer is ["B","F","G"]

Explanation

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The purpose of the Bishop's score is to:

A nurse is assisting in the care of a newborn who is 72 hr old and is receiving treatment for neonatal abstinence syndrome. Exhibits Which of the following data collection findings should the nurse identify as requiring immediate follow- up? (Select all that apply.).