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. 16. A nurse is caring for a newborn who is 4 hr old.

   Nurses' Notes

   Large ecchymotic caput succedaneum noted on occiput with molding of the skull. Anterior fontanel level and soft.
   Newborn's respirations are shallow and irregular.

   Newborn's skin color is consistent with their genetic background. Acrocyanosis noted. The newborn is active and moves all extremities except for left arm. Left arm remains at side during Moro reflex. Bilateral gluteal folds equal. Base of spine closed.
   Breastfed vigorously for 30 min.

   Drag 1 condition and 1 client finding to fill in each blank in the following sentence.
   
   The newborn most likely has as evidenced by Condition a clavicle fracture neonatal abstinence syndrome (NAS) developmental dysplasia of the hip (DDH) a subgaleal hemorrhage a congenital cardiac defect

A nurse is teaching a newborn's parent to care for the umbilical cord stump. Which of the following instructions should the nurse include?

A nurse is caring for a client who is 2 hr postpartum following a vaginal birth. Which of the following findings indicates the client's bladder is distended?

A nurse is caring for a client who is receiving opioid epidural analgesia during labor. Which of the following findings is the nurse's priority?

A nurse is caring for a preterm newborn who is in an incubator to maintain a neutral thermal environment. The father of the newborn asks the nurse why this is necessary. Which of the following responses should the nurse make?

A nurse is caring for a client who is a primigravida, at term, and having contractions but is stating that she is "not really sure if she is in labor or not." Which of the following should the nurse recognize as a sign of true labor?

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 the emergency department is caring for a client who comes to the emergency department reporting severe abdominal pain in the left lower quadrant. The provider suspects a ruptured ectopic pregnancy. Which of the following signs indicates to the nurse that the client has blood in the peritoneum?

A nurse is assessing a client who is receiving magnesium sulfate to treat pre-eclampsia. Which of the following findings should the nurse report to the provider? 

A nurse is assessing a newborn. Which of the following should the nurse understand is a clinical manifestation of pyloric stenosis?