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 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.

Choice A reason:

Heat facilitates the drainage of mucus for a premature newborn. This is incorrect because heat does not affect mucus drainage. Mucus drainage is more related to suctioning and hydration.

Choice B reason:

The newborn has a small body surface for his weight. This is incorrect because a small body surface area for weight would indicate a large newborn, not a premature one. A large newborn would have less risk of heat loss than a small one.

Choice C reason:

The newborn's temperature control mechanism is immature. This is correct because premature newborns have immature thermoregulation and are prone to hypothermia. Placing the newborn in an incubator helps maintain a stable temperature and prevent further complications.

Choice D reason:

Heat increases the flow of oxygen to the newborn's extremities. This is incorrect because heat does not directly affect oxygen delivery. Oxygen delivery is more related to ventilation, perfusion, and hemoglobin levels. The question is about a premature newborn who has signs of respiratory distress, such as nasal flaring, intercostal retractions, expiratory grunting, and mild cyanosis. These signs indicate that the newborn is having difficulty breathing and may have a condition such as respiratory distress syndrome, transient tachypnea of the newborn, or meconium aspiration syndrome. The nurse should place the newborn in an incubator to provide warmth and prevent heat loss, which can worsen respiratory distress. The nurse should also monitor the newborn's vital signs, oxygen saturation, blood gases, chest x-ray, and neonatal abstinence scoring system if indicated. The nurse should be prepared to administer oxygen, surfactant, or mechanical ventilation as ordered.