A nurse is caring for a newborn who is 56 hours old in the neonatal unit. Below are the exhibits.
A nurse reviews the assessment findings and determines the findings are consistent with which of the following complications? Each finding may support more than one disease process.
Jitteriness
Lethargy
Poor Feeding
Jaundice
Loose Stool
The Correct Answer is {"A":{"answers":"A,C"},"B":{"answers":"A,C"},"C":{"answers":"A,C"},"D":{"answers":"B"},"E":{"answers":"C"}}
- Jitteriness: This can be a sign of hypoglycemia in a newborn, and it may also be seen in Neonatal Abstinence Syndrome (NAS) due to withdrawal symptoms.
- Lethargy: Lethargy is common in hypoglycemia (due to low energy reserves) and can also be seen in Neonatal Abstinence Syndrome due to withdrawal effects.
- Poor Feeding: Hypoglycemia may cause poor feeding due to the lack of energy, and Neonatal Abstinence Syndrome can cause feeding difficulties because of withdrawal symptoms.
- Jaundice: Jaundice is a hallmark sign of Neonatal Jaundice, typically due to elevated bilirubin levels.
- Loose Stool: Loose stool can be a sign of Neonatal Abstinence Syndrome, as gastrointestinal disturbances are common in withdrawal. It is not typically associated with hypoglycemia or neonatal jaundice.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Placing the newborn in a radiant warmer is appropriate for managing hypothermia but does not directly address the signs of diaphoresis, jitteriness, and lethargy, which are indicative of hypoglycemia.
Choice B rationale
Monitoring the newborn's blood pressure is not the primary action needed for signs of hypoglycemia. The immediate need is to check blood glucose levels and address any hypoglycemia.
Choice C rationale
Initiating phototherapy is a treatment for hyperbilirubinemia (jaundice) and is not related to the signs of diaphoresis, jitteriness, and lethargy seen in hypoglycemia.
Choice D rationale
Obtaining blood glucose by heel stick is the correct action as the signs of diaphoresis, jitteriness, and lethargy are indicative of hypoglycemia. Checking blood glucose levels will help in diagnosing and managing the condition.
Correct Answer is F
Explanation
Choice A rationale
Stools are a normal occurrence in newborns and are not typically associated with significant complications. The frequency and consistency can vary, but abnormal stools would not explain the given vital signs.
Choice B rationale
Temperature control is vital in newborns, but the given temperature is slightly low and alone does not indicate a specific complication without additional context such as infection or environment.
Choice C rationale
Feeding difficulties can occur in newborns, but they would typically present with symptoms related to weight and growth rather than the specific vital signs provided.
Choice D rationale
Extremities’ conditions, such as cyanosis or poor circulation, could indicate complications, but the given vital signs are not directly indicative of extremity problems.
Choice E rationale
Hypoglycemia in newborns can present with signs like jitteriness or lethargy, but it does not directly correlate with the provided vital signs without additional glucose measurements.
Choice F rationale
Neonatal Abstinence Syndrome (NAS) includes symptoms such as high heart rate, respiratory rate, and temperature instability, which align with the newborn's vital signs.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.