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A nurse is assisting with the care of a newborn who is 4 hours old in the neonatal unit.

Exhibits

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client’s progress.

Answer and Explanation

The Correct Answer is []

Based on the provided information, here’s the completed diagram:

Potential Condition

Neonatal abstinence syndrome

Actions to Take

Reinforce with the parent to feed the newborn
Anticipate a prescription to obtain a capillary blood sample

Parameters to Monitor

Respiratory status
Temperature

Congenital Syphilis

Reasoning: The mother’s syphilis was treated successfully in the first trimester, and her subsequent tests (VDRL and RPR) were negative. This indicates that the infection was resolved, making congenital syphilis unlikely.

Hypoglycemia

Reasoning: While some symptoms like jitteriness and weak cry could suggest hypoglycemia, the newborn’s weight (4,366 g) and the absence of other typical signs like lethargy or seizures make this less likely. Additionally, there is no mention of a blood glucose test result indicating hypoglycemia.

Kernicterus

Reasoning: Kernicterus is a severe form of jaundice caused by high bilirubin levels. The newborn’s symptoms (jitteriness, weak cry, mottled extremities, acrocyanosis) do not align with the typical presentation of kernicterus, which includes severe jaundice, lethargy, and high-pitched crying. There is also no mention of elevated bilirubin levels.

Neonatal Abstinence Syndrome (NAS)

Reasoning: The newborn’s symptoms (jitteriness, weak cry, rapid respirations, restlessness, difficulty feeding, and decreased muscle tone) are consistent with NAS, which can occur due to maternal substance use during pregnancy. The positive urine drug screen for marijuana supports this diagnosis

Nursing Test Bank

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Correct Answer is D

Explanation

Choice A rationale

Purchasing furniture for the baby’s room is a common and healthy behavior during pregnancy. It indicates that the client is preparing for the baby’s arrival and is excited about the new addition to the family. This behavior is generally seen as positive and supportive of the pregnancy.

Choice B rationale

Being unsure about wanting an epidural during labor is a normal concern for many pregnant individuals. It reflects the client’s consideration of pain management options and their desire to make an informed decision. This is not typically seen as a psychosocial concern.

Choice C rationale

The partner planning to attend birthing classes with the client is a positive sign of support and involvement in the pregnancy. It indicates that the partner is engaged and willing to participate in the childbirth process, which can be beneficial for the client’s emotional well-being.

Choice D rationale

Expressing uncertainty about whether an older child will accept the new baby can indicate underlying anxiety or stress about family dynamics and the impact of the new baby on existing relationships. This concern may require further exploration and support to ensure the client’s emotional health.

A. Image of a newborn with toes fanning out when the sole of the foot is stroked. B. Image of a newborn with toes curling in when the sole of the foot is stroked. C. Image of a newborn with no response when the sole of the foot is stroked. D. Image of a newborn with the big toe bending down when the sole of the foot is stroked.

Correct Answer is A

Explanation

Choice A rationale

A positive Babinski reflex is characterized by the fanning out of the toes and the upward movement of the big toe when the sole of the foot is stroked. This reflex is normal in infants up to 2 years old and indicates an immature central nervous system. The presence of this reflex in older children or adults can indicate neurological issues.

Choice B rationale

Curling in of the toes when the sole of the foot is stroked is indicative of the plantar grasp reflex, not the Babinski reflex. The plantar grasp reflex is a different neurological response and does not indicate the same neurological development as the Babinski reflex.

Choice C rationale

No response when the sole of the foot is stroked could indicate a lack of neurological response or an issue with the sensory or motor pathways. This is not characteristic of a positive Babinski reflex and could be a sign of neurological impairment.

Choice D rationale

The big toe bending down when the sole of the foot is stroked is a normal response in older children and adults, known as the plantar reflex. This response indicates a mature central nervous system and is not characteristic of a positive Babinski reflex in infants.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who is at 23 weeks of gestation.Which of the following client statements should the nurse identify as a potential psychosocial concern?

Correct Answer is D

Explanation

A nurse is collecting data from a newborn.The nurse should recognize that which of the following images demonstrates a positive Babinski reflex?

Correct Answer is A

Explanation

A nurse is assisting with the care of a newborn who has neonatal abstinence syndrome.Which of the following actions should the nurse take first?

A nurse is assisting with the care of a client who is in labor and has received nalbuphine hydrochloride.Which of the following manifestations should the nurse identify as an adverse effect of this medication?

A nurse in an antepartum unit is assisting with the care of a client who has preeclampsia and is receiving IV magnesium sulfate therapy.For which of the following adverse effects should the nurse monitor and report to the provider?

A nurse is checking the reflexes of a newborn.Which of the following actions should the nurse use to elicit the Babinski reflex?

A nurse is preparing to administer metronidazole 2 g PO. The amount available is 500 mg tablets. How many tablets should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.) .

A nurse is reinforcing teaching about outpatient resources for a client who is recovering from a molar pregnancy.Which of the following statements by the client indicates an understanding of the teaching?