A nurse is assisting with the care of a newborn who is 4 hours old in the neonatal unit.
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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}
Explanation
The nurse should plan toB. check the client’s blood glucose levelandA. obtain a urine sample to test for ketones.
Explanation:
- Check the client’s blood glucose level: Given the client’s history of type 1 diabetes mellitus and her current symptoms (diaphoresis, clammy skin, headache, nausea, and weakness), it is crucial to check her blood glucose level to rule out hypoglycemia or hyperglycemia, despite the recent blood glucose reading of 120 mg/dL.
- Obtain a urine sample to test for ketones: Testing for ketones is important in diabetic patients, especially when they present with symptoms that could indicate diabetic ketoacidosis (DKA), such as nausea, weakness, and a history of type 1 diabetes.
Correct Answer is D
Explanation
Choice A rationale
Hypertension is not a common adverse effect of epidural anesthesia. In fact, epidurals can cause hypotension due to the blockade of sympathetic nerves.
Choice B rationale
Tachypnea is not typically associated with epidural anesthesia. Common side effects include low blood pressure and headache.
Choice C rationale
Tachycardia is not a common adverse effect of epidural anesthesia. More common side effects include low blood pressure and urinary retention.
Choice D rationale
Fever is a known adverse effect of epidural anesthesia. It can occur due to the body’s response to the epidural procedure.
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