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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A rationale

Accelerations are increases in the fetal heart rate (FHR) above the baseline, typically in response to fetal movement or uterine contractions. They indicate a healthy, well-oxygenated fetus and are not consistent with the described pattern of decelerations.

Choice B rationale

Late decelerations are characterized by a gradual decrease in FHR that begins after the contraction has started, with the lowest point of the deceleration (nadir) occurring after the peak of the contraction. They are associated with uteroplacental insufficiency and fetal hypoxia, which is not described in the scenario.

Choice C rationale

Early decelerations are a gradual decrease in FHR that mirrors the contraction, starting with the contraction and returning to baseline as the contraction ends. The nadir of the deceleration occurs at the peak of the contraction, which fits the pattern described.

Choice D rationale

Variable decelerations are abrupt decreases in FHR that can occur at any time during the contraction cycle, usually due to umbilical cord compression. They are not uniform in relation to contractions and can vary in duration, depth, and timing, unlike the described pattern.

A. Seek prophylactic treatment if cytomegalovirus is detected during pregnancy. B. A woman should avoid changing the cat litter box while pregnant. C. A woman should avoid crowded places during pregnancy. D. Obtain an immunization against Rubella early in pregnancy.

Correct Answer is B

Explanation

Choice A rationale

Prophylactic treatment for cytomegalovirus during pregnancy isn't generally recommended. CMV detection should lead to close monitoring rather than prophylactic treatment, as current treatments pose risks without guaranteed efficacy.

Choice B rationale

Avoiding cat litter is crucial during pregnancy to prevent toxoplasmosis infection, which can cause severe fetal harm, including hydrocephalus, mental disabilities, and seizures, by transferring through contact with cat feces.

Choice C rationale

While avoiding crowded places can reduce general infection risks, it is not specifically associated with preventing TORCH infections. TORCH infections refer to a set of perinatal infections that pose particular risks to fetal health.

Choice D rationale

Rubella immunization should be done before pregnancy, not during, as live vaccines carry risks. A woman should confirm immunity before conception to protect against congenital rubella syndrome.

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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?

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Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

A nurse is reviewing ways to prevent a TORCH infection during pregnancy with a group of newly licensed nurses.Which statement by the nurse indicates understanding of the teaching?

Correct Answer is B

Explanation

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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?