A nurse is caring for a newborn client.
The assessment findings include a high-pitched cry, increased muscle tone, frequent yawning, poor feeding with projectile vomiting, and tachypnea.
What condition does the nurse suspect?
Hyperbilirubinemia.
Neonatal abstinence syndrome.
Respiratory distress syndrome.
Necrotizing enterocolitis.
The Correct Answer is B
Choice A rationale
Hyperbilirubinemia presents with jaundice (yellowing of the skin and eyes) and is caused by excess bilirubin in the blood. It doesn't typically involve a high-pitched cry, increased muscle tone, or projectile vomiting.
Choice B rationale
Neonatal abstinence syndrome occurs in newborns exposed to addictive opiate drugs while in the mother’s womb. Symptoms include high-pitched crying, increased muscle tone, yawning, poor feeding with vomiting, and tachypnea due to drug withdrawal.
Choice C rationale
Respiratory distress syndrome is primarily characterized by breathing difficulties, including rapid, shallow breathing and a grunting sound. Symptoms do not typically include high-pitched cry or projectile vomiting.
Choice D rationale
Necrotizing enterocolitis involves severe inflammation and necrosis of the intestines. Symptoms include abdominal distension, vomiting bile, bloody stools, and apnea but not a high-pitched cry or increased muscle tone.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["0724"]
Explanation
Step 1 is: October 17 + 7 days = October 24.
Step 2 is: October 24 - 3 months = July 24.
Step 3 is: July 24 + 1 year = July 24.
Answer: 0724 (July 24)
Correct Answer is B
Explanation
Choice A rationale
Monitoring the newborn's blood pressure does not directly address symptoms like diaphoresis, jitteriness, and lethargy. These symptoms indicate an immediate need to check blood glucose levels for hypoglycemia.
Choice B rationale
Obtaining blood glucose by heel stick is the correct step because diaphoresis, jitteriness, and lethargy in a newborn are classic signs of hypoglycemia. Timely detection and correction of blood glucose levels are critical.
Choice C rationale
Placing the newborn in a radiant warmer might help maintain body temperature but does not address the root cause of the symptoms, which is likely hypoglycemia.
Choice D rationale
Initiating phototherapy is used to treat jaundice (high bilirubin levels) and is not indicated for managing symptoms of hypoglycemia like diaphoresis, jitteriness, and lethargy.
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