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A nurse is caring for a newborn.

Exhibits

Drag words from the choices below to fill in each blank in the following sentence. The client is at risk for developing 

and
Answer and Explanation

The Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"D"}

The client is at risk for developing transient tachypnea of the newborn and hypoglycemia.

Rationale

Target 1: Transient Tachypnea of the Newborn (TTN)

  • Transient tachypnea of the newborn (TTN) is a condition characterized by rapid breathing (tachypnea) in the first few hours after birth, typically caused by delayed clearance of fetal lung fluid. It often resolves within 24-48 hours.
  • The newborn in the exhibit has a respiratory rate that is increasing: at 64 minutes, the rate is 68/min, and it increases to 76/min by 0700. This is significantly higher than the normal respiratory rate for a newborn (30-60/min) and is a key sign of tachypnea.
  • Given the increased respiratory rate and the newborn’s age, transient tachypnea of the newborn is a likely concern. This condition is particularly common in late preterm and full-term infants who experience some delay in clearing fetal lung fluid after birth.

Target 2: Hypoglycemia

  • Hypoglycemia in newborns can occur due to several factors, such as increased metabolic demand (which could be indicated by the tachycardia and respiratory rate), poor feeding, or stress during delivery.
  • Tachycardia is one of the early signs of hypoglycemia in newborns, as the body responds to low blood sugar by increasing the heart rate to compensate for the lack of energy.
  • The heart rate is consistently high, with values of 154/min and 156/min during the assessment. This tachycardia could be indicative of hypoglycemia, as the body works harder to compensate for low glucose levels.

Rationale for other conditions;

Bronchopulmonary Syndrome:

This condition refers to lung diseases like bronchopulmonary dysplasia (BPD), which typically occurs in premature infants who have had prolonged mechanical ventilation. There are no signs of this condition in the current assessment, such as the need for respiratory support or signs of chronic lung disease.

The newborn's respiratory rate and tachycardia are more consistent with transient tachypnea rather than a chronic condition like bronchopulmonary syndrome.

Tachycardia:

Tachycardia itself is a symptom, not a diagnosis. The infant's tachycardia could be a response to hypoxia or hypoglycemia, so the condition causing the tachycardia needs to be addressed (which is hypoglycemia and transient tachypnea of the newborn).

 


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Related Questions

Correct Answer is B

Explanation

A. Spilled solution should not be left on the sterile field. The sterile field should be maintained and any spills must be handled properly.
B. The cap should be placed sterile-side up to prevent contamination and preserve sterility.
C. The bottle should be held outside the sterile field to avoid contamination.
D. The label should be facing the palm to ensure the bottle is handled correctly without contaminating the sterile solution.

Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"A"}

Explanation

The nurse should first anticipate the need to Obtain IV access then Prepare to administer IV fluids.

Rationale

First Anticipated Step: Obtain IV Access:

In a client with hypotension and anemia, immediate IV access is crucial to administer fluids or blood

products to stabilize the client’s condition before the endoscopy. Given the client’s low blood pressure and heart rate, they may need IV fluids (such as saline or Ringer's lactate) to help improve circulation and maintain perfusion. This is essential before proceeding with further interventions like the planned endoscopy.

Second Anticipated Step:

Prepare to administer IV fluids:

The client's low blood pressure and the potential for significant blood loss suggest that IV fluids will be necessary to restore blood volume and improve hemodynamic stability before endoscopy. Normal saline or Lactated Ringer's are commonly used for volume resuscitation in this scenario.

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