A nurse is caring for a newborn who is 72 hr old.

Physical Examination

1100:

Neonatal Abstinence Scoring System (NAS)

Excessive high-pitched cry-2 Sleeps <2 hr 2
Hyperactive Moro reflex=2 Moderate-severe tremors disturbed=2 Increased muscle tone=2
Fever <37.2 to 38.2° C (99 to 100.8° F)=1

Excessive sucking=1 Frequent sneezing=1

Frequent yawning-1 Loose stools=2 Poor feeding=2
Respiratory rate > 60/min=1 Mottling-1
NAS score 20

The nurse is planning to contact the provider regarding the newborn's status. Which of the following prescriptions should the nurse anticipate? Select the 3 interventions the nurse should anticipate.

1. A nurse is caring for a newborn who is 30 min old.

Nurses' Notes

1030:

Newborn placed on the birth parent's abdomen immediately following birth. Mouth and nose suctioned with bulb syringe. Dried and stimulated. Strong cry noted. Moving all extremities. Flexed tone noted. Acrocyanosis present.

1100:

Newborn is alert and active. Respirations rapid and shallow with occasional expiratory grunting, Fine crackles auscultated throughout lung fields. Small amount of green-stained vernix present in skin folds. Fingernails stained green. Molding of skull and generalized soft occipital swelling noted. Vital Signs

1030:

Axillary temperature 36.9° C (98.4° F)

Heart rate 170/min Respiratory rate 72/min

1100:

Birth weight 4,025 gm (8 lb 14 oz) (Appropriate for Gestational Age) Axillary temperature 36.7° C (97.8° F)

Heart rate 162/min Respiratory rate 80/min

After reviewing the information in the newborn's medical record, which of the following complications should the nurse identify as posing the greatest risk? The condition that poses the

greatest risk to the newborn is meconium aspiration syndrome due to color of amniotic fluid.

Condition meconium aspiration syndrome meconium ileus

cold stress hypoglycemia jaundice Finding color of amniotic fluid birth weight acrocyanosis gestational age

Apgar scores

Nurses' Notes 0800:

Newborn placed on radiate warmer. Color consistent with newborn's genetic background. Acrocyanosis present. Mild grunting, nasal flaring and intermittent retractions noted.

0830:

Grunting, nasal flaring, and sternal retractions noted. Color consistent with newborn's genetic background. Acrocyanosis present.

Select the 4 findings the nurse should report to the provider.

r.

A nurse in an antepartum unit is triaging clients. Which of the following clients should the nurse see first?

A nurse is caring for an adolescent client who has pelvic inflammatory disease as a consequence of a sexually transmitted infection, and will need intravenous antibiotic therapy. The client tells the nurse, "My parents think I am a virgin. I don't think I can tell them I have this kind of an infection." Which of the following responses should the nurse make?

A nurse is caring for a postpartum client.

Click to highlight the client statements that indicate an understanding of the discharge teaching.

"Because of my baby's weight loss, I need to supplement with formula after breastfeeding."

"I should make sure that my baby feeds 8 to 12 times per day."

"I should cover my sore nipples with plastic-lined breast pads after every feeding."

"My baby's stools should turn to a yellow color within the next day or two.

I can increase my milk supply by drinking more water.

I should expect my breasts to become harder, warmer, and more tender when my milk comes in."

A nurse is caring for a newborn 8 hours of age

Which of the following assessment findings require follow-up by the nurse?

Click to highlight the statements in the assessment findings that require follow-up by the nurse.

Axillary temperature 36.1°C (97°F)

Heart rate 160/min

Respiratory rate 78/min

Newborn is sleeping in their birth parent's arms. Awakens with stimulation. Yellow discoloration noted of sclera and oral mucosal Lung sounds clear bilaterally. Nasal flaring present. Fontanel level and soft with large ecchymotic caput succedaneum noted. Blood-tinged mucus noted at the vaginal opening. Has voided and stooled one time since birth. Uric acid crystals observed in the urine. Breastfed x 1 in the past 6 hr for 10 min

A nurse is caring for a client who is at 22 weeks of gestation and has been unable to control her gestational diabetes mellitus with diet and exercise. The nurse should anticipate a prescription from the provider for which of the following medications for the client?

A nurse in a prenatal clinic is caring for a client who is suspected of having a hydatidiform mole. Which of the following findings should the nurse expect to observe in this client?

A nurse is caring for a client who is 2 hr postpartum. The nurse notes that the client soaked a perineal pad in 10 min, the client's skin color is ashen, and she states she feels weak and light headed. After applying oxygen via nonrebreather face mask at 10 L/min which of the following actions should the nurse take next?

A nurse is caring for a client who has just delivered her first newborn. The nurse anticipates hyperbilirubinemia due to Rh incompatibility. The nurse should understand that hyperbilirubinemia occurs with Rh incompatibility for which of the following reasons?