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A nurse is caring for a newborn immediately following birth.

Exhibits

The nurse is assessing the newborn 24 hr later.

How should the nurse interpret the findings?

For each finding, click to specify whether the finding is unrelated to the diagnosis, an indication that the client's condition is improving, or an indication that the client's condition is worsening.

Findings 24 hr later:

A.

Color: Consistent with genetic background.

B.

Axillary temperature 36.3° C (97.4°F). Reflex irritability: cry.

C.

Muscle tone: flaccid.

D.

Respiration effort: good cry.

E.

Heart rate 140/min.

Answer and Explanation

The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"C"},"D":{"answers":"B"},"E":{"answers":"B"}}

  • Color: Consistent with genetic background

    • Interpretation: B) Sign of potential improvement
    • Rationale: The newborn’s color being consistent with their genetic background indicates a normal adjustment and is not a sign of deterioration. This suggests improvement from the initial condition of acrocyanosis.

  • Axillary Temperature: 36.3°C (97.4°F)

    • Interpretation: B) Sign of potential improvement
    • Rationale: The axillary temperature is within the normal range (36.1°C to 37.2°C), which is a positive sign and suggests that the newborn is maintaining normal body temperature.

  • Reflex Irritability: Cry

    • Interpretation: B) Sign of potential improvement
    • Rationale: A good cry indicates normal reflex irritability and is a positive sign of neurological and overall well-being.

  • Muscle Tone: Flaccid

    • Interpretation: C) Sign of potential worsening condition
    • Rationale: Flaccid muscle tone is concerning as it might indicate a worsening condition or potential neurological issues. It is less typical for muscle tone to be flaccid after the initial adjustment period.

  • Respiration Effort: Good cry

    • Interpretation: B) Sign of potential improvement
    • Rationale: A good cry indicates effective respiration and is a positive sign of the newborn’s respiratory status.

  • Heart Rate: 140/min

    • Interpretation: B) Sign of potential improvement
    • Rationale: The heart rate is within the normal range for newborns (120-160/min), indicating that the cardiovascular system is functioning properly.


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Related Questions

Correct Answer is D

Explanation

Choice A rationale:
Placing the client in a semi-Fowler’s position for 1 hr after administration is not necessary.
Choice B rationale:
Allowing the medication to reach room temperature prior to administration is not necessary.
Choice C rationale:
Instructing the client to avoid urinary elimination until after administration is not necessary.
Choice D rationale:
Verifying that informed consent is obtained prior to administration is crucial as it ensures the client is aware of the procedure and its potential risks.

Correct Answer is A

Explanation

Choice A rationale:
Poor feeding is a common manifestation in newborns of mothers who used methadone during pregnancy.
Choice B rationale:
A weak cry is not specifically associated with methadone use during pregnancy.
Choice C rationale:
An absent Moro reflex is not specifically associated with methadone use during pregnancy.
Choice D rationale:
A respiratory rate of 30/min is within the normal range for a newborn (30-60 breaths per minute) and does not indicate methadone exposure.

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