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 D
Explanation
Choice A rationale
Administering oxygen may help with symptoms like headache and weakness, but it does not address the underlying issue of poor circulation and potential shock. Elevating the legs is more effective in improving blood flow to vital organs.
Choice B rationale
Offering an ice pack is not appropriate for the symptoms described. The client is showing signs of shock, and an ice pack would not address the underlying issue.
Choice C rationale
Providing a warm blanket may offer comfort, but it does not address the symptoms of shock. Elevating the legs is a more direct intervention to improve circulation and stabilize the client.
Choice D rationale
Elevating the client’s legs helps improve venous return to the heart, increasing cardiac output and stabilizing blood pressure. This is a critical intervention for a client showing signs of shock.
Correct Answer is D
Explanation
Choice A rationale
White blood cell count is not an indicator of anemia. It measures immune function and can indicate infection or inflammation.
Choice B rationale
Urine specific gravity does not identify the risk for pregnancy-induced hypertension. It measures the concentration of urine and can indicate hydration status.
Choice C rationale
Sedimentation rate does not check for signs of cancer. It measures inflammation in the body and can indicate various conditions.
Choice D rationale
Platelet count identifies if the client is at risk for bleeding. Low platelet levels can indicate a higher risk of bleeding and are important to monitor during pregnancy. .
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