A nurse is caring for a newborn in the neonatal unit following delivery.

Complete the following sentence by using the list of options.
The nurse should further evaluate

and

to determine if the newborn is experiencing a complication.

Answer and Explanation

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

The nurse should further evaluate respiratory characteristics and muscle tone to determine if the newborn is experiencing a complication.

Rationale for correct answers
Respiratory characteristics are critical to assess because irregular and shallow breathing in a newborn can indicate neurological or respiratory dysfunction. Normal neonatal respiratory rate ranges from 30 to 60 breaths per minute with regular pattern; deviations may signal distress or central nervous system issues. Muscle tone evaluation is essential since increased tone with tremors suggests possible neurologic irritability or withdrawal. Normal newborn muscle tone should be moderate, neither hypotonic nor hypertonic, with symmetrical movement. These signs correlate with the high-pitched cry, tremors, and exaggerated reflexes noted, which may indicate neurological complications such as withdrawal syndrome or hypoxic-ischemic encephalopathy.

Rationale for incorrect answers
Heart rate (A) is important but was not reported abnormal; normal neonatal heart rate ranges from 120 to 160 beats per minute and the absence of murmurs suggests no cardiac compromise. Temperature (C) is less urgent as mucous membranes are moist and skin warm and dry, indicating stable thermoregulation; normal newborn temperature is 36.5–37.5°C. Feeding patterns (D) appear adequate with no difficulty reported, making this less immediately concerning.

Rationale for incorrect answers
Moro reflex (A) and Babinski reflex (B) are both present and exaggerated, which may be reactive but less specific for immediate concern than muscle tone abnormalities. Skin color (D) is normal without cyanosis or jaundice, reducing the likelihood of hypoxia or hemolytic issues.

Take home points

Respiratory pattern irregularities in newborns may indicate neurological or respiratory dysfunction.
Abnormal muscle tone and tremors are key signs of potential neurological complications.
Normal heart rate, temperature, feeding, and skin color reduce likelihood of cardiac or systemic illness.
Reflex exaggeration alone is less specific than muscle tone and respiratory changes for early complication detection.

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Correct Answer is D

Explanation

Choice A rationale

Hydrocodone is an opioid analgesic, but it is typically used for moderate to severe pain and is not commonly administered as a primary agent for severe active labor pain due to its slower onset and potential for more pronounced maternal and neonatal respiratory depression compared to other rapid-acting opioids.

Choice B rationale

Naproxen is a nonsteroidal anti-inflammatory drug (NSAID) primarily used for mild to moderate pain and inflammation. It is generally not effective enough for severe labor pain and is contraindicated in late pregnancy due to potential adverse effects on fetal circulation, such as premature closure of the ductus arteriosus.

Choice C rationale

Naloxone hydrochloride is an opioid antagonist used to reverse opioid-induced respiratory depression. Administering naloxone during active labor would reverse the effects of any pain medication given, exacerbating the client's pain and potentially precipitating opioid withdrawal symptoms, thus it is not an appropriate pain management strategy.

Choice D rationale

Fentanyl citrate is a potent, rapid-acting synthetic opioid analgesic commonly used for severe pain during active labor. Its quick onset and short duration of action make it suitable for intermittent administration, allowing for effective pain relief with a lower risk of prolonged neonatal respiratory depression compared to longer-acting opioids.

A. Client rested well during the night with blood pressures remaining below 160/110 mm Hg. B. Headache decreased in intensity at midnight. C. Client now rates their pain from headache as 7 on a scale of 0 to 10. D. Client reports that they continue to see “spots” in vision. E. Client is experiencing mild epigastric discomfort that began around 0300. F. Patellar deep tendon reflexes have remained 3+ to 4+ during the night, with positive clonus noted. G. Urine output has ranged from 25 to 55 mL/hr.

Correct Answer is ["C","D","E","F"]

Explanation

Choice A rationale: Blood pressure readings below 160/110 mm Hg overnight indicate some level of blood pressure control, which is a positive sign in hypertensive pregnancy conditions. The goal is to maintain pressures below this threshold to reduce risk of end-organ damage. Stable or lower pressures reduce cerebral and placental ischemia risk. Therefore, resting well with controlled BP suggests no immediate worsening, indicating progression is stable at this point.

Choice B rationale: A decrease in headache intensity temporarily is a favorable clinical sign. Headache in preeclampsia is caused by cerebral edema and vasospasm, so improvement indicates less neurological irritation or pressure. However, this is a transient improvement and must be interpreted cautiously, but the reduction alone does not indicate a worsening condition, so it is not a marker of poor progression.

Choice C rationale: An increased headache intensity rating to 7/10 signals significant neurological involvement and increased cerebral irritation, typical of worsening preeclampsia or impending eclampsia. Severe headaches in pregnancy with hypertension indicate cerebral vasospasm or edema, which may lead to seizures if untreated. This is a critical sign requiring urgent intervention to prevent maternal and fetal morbidity.

Choice D rationale: Persistent visual disturbances such as seeing spots or flashes are neurological symptoms indicating retinal or cerebral involvement due to vasospasm, ischemia, or edema. These symptoms are common in severe preeclampsia and herald worsening disease. Visual symptoms result from endothelial dysfunction affecting cerebral and retinal vessels, requiring immediate evaluation to prevent progression to eclampsia.

Choice E rationale: Epigastric discomfort reflects stretching or ischemia of the liver capsule from hepatic involvement in severe preeclampsia or HELLP syndrome. This pain typically presents as right upper quadrant or epigastric pain due to hepatocellular injury or microvascular thrombosis. It is a warning sign of multisystem involvement and potential progression to life-threatening complications such as hepatic rupture.

Choice F rationale: Hyperactive deep tendon reflexes (3+ to 4+) and positive clonus are clinical signs of central nervous system irritability caused by increased excitability of motor neurons. This occurs due to cerebral vasospasm and ischemia in severe preeclampsia and predicts risk for seizures (eclampsia). These neurological signs are crucial in assessing disease severity and necessitate urgent management.

Choice G rationale: Urine output between 25 and 55 mL/hr approaches the lower limit of normal (normal ≥30 mL/hr). Reduced urine output in preeclampsia indicates renal hypoperfusion or injury due to endothelial dysfunction and vasospasm, which can progress to acute kidney injury. Monitoring urine output is essential as oliguria signals worsening renal compromise, increasing maternal and fetal risk.

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A nurse is caring for a newborn in the neonatal unit following delivery. Complete the following sentence by using the list of options. The nurse should further evaluate ________ and ________ to determine if the newborn is experiencing a complication.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is experiencing severe pain during active labor. Which of the following medications should the nurse plan to administer and document in the client's medical record?

Correct Answer is D

Explanation

Correct Answer is ["C","D","E","F"]

Explanation

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A nurse is caring for a newborn in the neonatal unit following delivery.

Complete the following sentence by using the list of options.
The nurse should further evaluate

and

to determine if the newborn is experiencing a complication.