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A nurse is caring for a newborn in the neonatal intensive care unit (NICU).

Exhibits

A nurse reviews the assessment findings and determines the findings are consistent with which of the following complications? For each assessment finding, click to specify if the assessment finding is consistent with hypoglycemia or neonatal abstinence syndrome (NAS). Each finding may support more than one disease process.

A.

Jittery extremities

B.

Poor sucking reflex

C.

Excessive sweating

D.

Irritability

E.

Weak cry

F.

Mild tremors

G.

Low blood glucose level

H.

Positive urine toxicology

Answer and Explanation

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

  1. Jittery Extremities
    • Hypoglycemia: Jittery extremities are a common sign of low blood glucose levels.
    • Neonatal Abstinence Syndrome: Jitteriness can occur due to withdrawal symptoms in newborns exposed to opioids.
  2. Poor Sucking Reflex
    • Hypoglycemia: Newborns with low blood glucose levels may have difficulty feeding and a poor sucking reflex.
    • Neonatal Abstinence Syndrome: Poor feeding and sucking reflex can be part of withdrawal symptoms in newborns.
  3. Excessive Sweating
    • Hypoglycemia: Excessive sweating can be a symptom of low blood glucose levels.
    • Neonatal Abstinence Syndrome: Sweating is one of the possible signs of withdrawal in newborns.
  4. Irritability
    • Hypoglycemia: Irritability can result from low blood glucose levels.
    • Neonatal Abstinence Syndrome: Irritability is a common symptom of withdrawal in newborns exposed to opioids.
  5. Weak Cry
    • Hypoglycemia: A weak cry can be a symptom of low blood glucose levels.
    • Neonatal Abstinence Syndrome: Weak cry can also be part of withdrawal symptoms in newborns.
  6. Mild Tremors
    • Hypoglycemia: Tremors or shaking can be a sign of low blood glucose levels.
    • Neonatal Abstinence Syndrome: Tremors are common withdrawal symptoms in newborns exposed to opioids.
  7. Low Blood Glucose Level
    • Hypoglycemia: A blood glucose level of 40 mg/dL is considered low and indicates hypoglycemia.
    • Neonatal Abstinence Syndrome: Low blood glucose level is not a direct indicator of NAS but may occur due to poor feeding.
  8. Positive Urine Toxicology
    • Hypoglycemia: Not relevant.
    • Neonatal Abstinence Syndrome: Positive urine toxicology for opioids indicates in utero exposure to opioids, which can lead to NAS.


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Related Questions

Correct Answer is A

Explanation

Choice A rationale

Fever, tachycardia, abdominal pain, and purulent discharge are classic signs of endometritis, which is a postpartum infection of the uterine lining, indicating an inflammatory response to bacterial invasion.

Choice B rationale

Hypertension, headache, blurry vision, and chest pain are symptoms more indicative of preeclampsia or hypertensive disorders, not endometritis, which primarily affects the reproductive system.

Choice C rationale

Hyperglycemia, dehydration, and frequent urination are indicative of diabetes mellitus, particularly in cases of diabetic ketoacidosis, not associated with postpartum uterine infections.

Choice D rationale

Hypothermia, bradycardia, and jaundice suggest liver dysfunction or severe infections leading to sepsis, but these are not primary manifestations of endometritis which involves local uterine infection.

Correct Answer is A

Explanation

Choice A rationale

Anemia in pregnancy requires increased iron intake to support hemoglobin production, essential for oxygen transport in the blood. Iron-rich foods, such as red meat and leafy greens, are recommended.

Choice B rationale

Decreasing protein intake is counterproductive for anemic pregnant clients. Protein is vital for overall health and fetal development, and adequate intake should be maintained.

Choice C rationale

Calcium-rich foods are important but do not directly address anemia. They support bone health, and while necessary, they do not substitute the need for increased iron in anemic clients.

Choice D rationale

Vitamin C intake should be increased alongside iron-rich foods as it enhances iron absorption. However, increasing vitamin C alone does not suffice to correct anemia without adequate iron intake.

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