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.

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