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.).

Choice A:

Blood pressure. The normal blood pressure range for a newborn is 60 to 80 mm Hg systolic and 40 to 50 mm Hg diastolic. The baby's blood pressure is low, which could indicate shock, dehydration, infection, or heart failure. This requires immediate follow-up to identify and treat the cause.

Choice B:

Gastrointestinal disturbances. Gastrointestinal disturbances such as vomiting and diarrhea are common symptoms of neonatal abstinence syndrome (NAS), which is a withdrawal syndrome of infants after birth caused by in-utero exposure to drugs of dependence, most commonly opioids. These symptoms are not life-threatening and can be managed with supportive care such as hydration, nutrition, and comfort measures.

Choice C:

Skin color. Skin color is not a reliable indicator of NAS, as it can vary depending on the baby's ethnicity, temperature, oxygenation, and circulation. Skin color alone does not require immediate follow-up unless it is accompanied by other signs of distress such as cyanosis, pallor, or jaundice.

Choice D:

NAS score. NAS score is a tool used to assess the severity of withdrawal symptoms in infants with NAS. It includes items such as tremors, irritability, sleep problems, muscle tone, reflexes, seizures, yawning, sneezing, feeding, vomiting, stooling and temperature. A high NAS score indicates that the baby needs more intensive treatment such as medication to ease the withdrawal process. A low NAS score indicates that the baby is coping well and may not need medication. The NAS score should be monitored frequently and adjusted according to the baby's response.

Choice E:

Temperature. The normal temperature range for a newborn is 36.5 to 37.5°C (97.7 to 99.5°F). The baby's temperature is high, which could indicate infection, dehydration or hyperthermia. This requires immediate follow-up to identify and treat the cause.

Choice F:

Oxygen saturation. The normal oxygen saturation range for a newborn is 95 to 100%. The baby's oxygen saturation is within the normal range and does not require immediate follow- up unless it drops below 90% or rises above 100%, which could indicate hypoxia or hyperoxia respectively.

Choice G:

Central nervous system disturbances. Central nervous system disturbances such as seizures, tremors, irritability, and overactive reflexes are common symptoms of NAS. These symptoms are not life-threatening and can be managed with supportive care such as swaddling, rocking, dimming lights, and reducing noise.

Choice H:

Respiratory rate. The normal respiratory rate range for a newborn is 40 to 60 breaths per minute. The baby's respiratory rate is high, which could indicate respiratory distress, infection, pain, or anxiety. This requires immediate follow-up to identify and treat the cause.

Choice A:

Temperature is not a priority finding to report to the provider. The newborn's temperature may vary slightly depending on the environment and the method of measurement. A normal temperature range for a newborn is 36.5°C to 37.5°C (97.7°F to 99.5°F).

Choice B:

Respiratory findings are important to report to the provider because the newborn had a low Apgar score at 1 minute and required positive pressure ventilation and oxygen. The nurse should assess the newborn's respiratory rate, effort, breath sounds, and oxygen saturation. Any signs of respiratory distress, such as tachypnea, grunting, retractions, nasal flaring, or cyanosis, should be reported immediately.

Choice C:

Serum glucose is a critical finding to report to the provider because the newborn is at risk for hypoglycemia due to the abruptio placenta and the emergency cesarean birth. Hypoglycemia can cause neurological damage and seizures in newborns. A normal serum glucose level for a newborn is 40 to 60 mg/dL.

Choice D:

Hematocrit is a significant finding to report to the provider because the newborn may have polycythemia or anemia due to the abruptio placenta and the blood loss during delivery.

Polycythemia can cause hyperviscosity and thrombosis, while anemia can cause hypoxia and shock. A normal hematocrit level for a newborn is 42% to 65%.

Choice E:

White blood cell count is not a priority finding to report to the provider. The newborn's white blood cell count may be elevated due to the stress of birth or a maternal infection. A normal white blood cell count for a newborn is 9,000 to 30,000/mm3.

Choice F:

Hemoglobin is an important finding to report to the provider because the newborn may have polycythemia or anemia due to the abruptio placenta and the blood loss during delivery.

Hemoglobin is the main component of red blood cells that carries oxygen to the tissues. A normal hemoglobin level for a newborn is 14 to 24 g/dL.

Choice G:

Heart rate is a vital finding to report to the provider because the newborn had a non- reassuring fetal heart rate during labor and delivery. The nurse should monitor the newborn's heart rate and rhythm for any signs of bradycardia, tachycardia, or arrhythmias. A normal heart rate range for a newborn is 110 to 160 beats per minute.