A nurse is caring for a newborn who is 4 hours old.

The newborn is lying in a bassinet, lightly swaddled.

The newborn is noted to be jittery with a weak cry when disturbed. Extremities are mottled with acrocyanosis.
Respirations are rapid and unlabored.

What condition is the newborn most likely experiencing? What are two actions the nurse should take to address that condition, and what are two parameters the nurse should monitor to assess the newborn’s progress?

Hypoglycemia

Neonatal Abstinence Syndrome

Cold Stress

Respiratory Distress Syndrome

Answer and Explanation

The Correct Answer is A

Choice A rationale
The newborn’s symptoms of jitteriness, weak cry, mottled extremities with acrocyanosis, and rapid, unlabored respirations are indicative of hypoglycemia. Hypoglycemia in the newborn period can be caused by several factors, including maternal diabetes (gestational or pre- existing), preterm birth, and sepsis. The nurse should take actions to address this condition, such as ensuring the newborn is warm, initiating early feeding to provide the newborn with glucose, and monitoring blood glucose levels.
Choice B rationale
Neonatal Abstinence Syndrome (NAS) is a group of problems that occur in a newborn who was exposed to addictive opiate drugs while in the mother’s womb. NAS can cause a wide range of symptoms such as excessive crying, poor feeding, and seizures. However, the symptoms described in the question are more indicative of hypoglycemia.
Choice C rationale
Cold stress can occur in newborns who are unable to maintain their body temperature within a normal range. While some of the symptoms described, such as mottled skin and acrocyanosis, can occur with cold stress, the presence of jitteriness and a weak cry are more indicative of hypoglycemia.
Choice D rationale
Respiratory Distress Syndrome (RDS) is a common problem in premature babies and is caused by a lack of surfactant in the lungs. While rapid, unlabored respirations can be a sign of RDS, the other symptoms described in the question, such as jitteriness and a weak cry, are not typically associated with RDS2.

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Correct Answer is C

Explanation

Choice A rationale
Polyuria, or excessive urination, is not typically associated with the administration of an epidural block with an opioid analgesic.
Choice B rationale
Bilateral crackles in the lungs can be a sign of a respiratory condition such as pneumonia or heart failure. However, they are not a common side effect of an epidural block with an opioid analgesic.
Choice C rationale
Hypotension, or low blood pressure, is a known side effect of epidural analgesia. This is due to the blockade of the sympathetic chain, which can contribute to hypotension. Therefore, it is important for the nurse to monitor the client’s blood pressure during the administration of an epidural block with an opioid analgesic.
Choice D rationale
Hyperglycemia, or high blood sugar, is not typically a side effect of an epidural block with an opioid analgesic. Hyperglycemia is more commonly associated with conditions such as diabetes.

A. “WBC Count 11,000/mm (5,000 to 10,000/mm?).”. B. “Fasting blood glucose 180 mg/dL (74 to 106 mg/dL).”. C. “Hematocrit 37% (37% to 47%).”. D. “Creatinine 0.9 mg/dL (0.5 to 1 mg/dL).”.

Correct Answer is B

Explanation

Choice A rationale
A WBC count of 11,000/mm is slightly above the normal range (5,000 to 10,000/mm), but it is not uncommon for the WBC count to increase during pregnancy due to physiological changes and increased stress on the body. However, a significantly elevated WBC count could indicate an infection or other medical condition, so it should be monitored closely.
Choice B rationale
A fasting blood glucose level of 180 mg/dL is significantly above the normal range (74 to 106 mg/dL), indicating hyperglycemia. This could be a sign of gestational diabetes, a condition that can develop during pregnancy and cause high blood sugar levels. Gestational diabetes can increase the risk of various pregnancy complications, including preeclampsia, premature birth, and having a baby with a high birth weight. Therefore, this finding should be reported to the provider immediately.
Choice C rationale
A hematocrit level of 37% is within the normal range (37% to 47%), so it would not typically be a cause for concern.
Choice D rationale
A creatinine level of 0.9 mg/dL is within the normal range (0.5 to 1 mg/dL), so it would not typically be a cause for concern.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing care to a client who is receiving an epidural block with an opioid analgesic. Which of the following findings should the nurse monitor as a potential adverse effect of the medication?

Correct Answer is C

Explanation

“A nurse is reviewing laboratory findings for a patient who is at 20 weeks of gestation. Which of the following findings should the nurse report to the provider?”

Correct Answer is B

Explanation

A nurse is caring for a client who is hypotensive following the administration of epidural anesthesia. Which action should the nurse take?

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