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A nurse is caring for a newborn who is 56 hours old in the neonatal unit. Below are the exhibits.

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.

A.

Jitteriness

B.

Lethargy

C.

Poor Feeding

D.

Jaundice

E.

Loose Stool

Answer and Explanation

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

  1. 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.
  2. Lethargy: Lethargy is common in hypoglycemia (due to low energy reserves) and can also be seen in Neonatal Abstinence Syndrome due to withdrawal effects.
  3. 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.
  4. Jaundice: Jaundice is a hallmark sign of Neonatal Jaundice, typically due to elevated bilirubin levels.
  5. 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.


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Related Questions

Correct Answer is ["A","B","C","D"]

Explanation

Choice A rationale

Respiratory assessment is crucial postpartum, especially with an elevated respiratory rate. It helps detect any respiratory distress or complications early.

Choice B rationale

Hemoglobin level assessment is essential to identify anemia or excessive blood loss during delivery, which can compromise the mother's health.

Choice C rationale

A heart rate of 110/min is above the normal range and might indicate tachycardia, which requires monitoring and possibly intervention.

Choice D rationale

A constant trickle of blood at the vagina could indicate postpartum hemorrhage, necessitating immediate medical attention.

Correct Answer is D

Explanation

Choice A rationale

Unstable vital signs in a newborn could be attributed to various causes such as infection, respiratory issues, or cardiovascular problems. It is not directly linked to the absence of phytonadione injection.

Choice B rationale

Low glucose levels in a newborn can result from conditions like prematurity, maternal diabetes, or feeding issues and are not a direct consequence of the absence of a phytonadione injection.

Choice C rationale

Acrocyanosis, a bluish discoloration of the hands and feet, is a common and benign finding in newborns due to immature blood circulation and is not related to the absence of phytonadione.

Choice D rationale

Phytonadione (vitamin K) is essential for blood clotting. Absence of this injection can lead to bleeding issues, such as oozing at circumcision sites, due to vitamin K deficiency bleeding (VKDB).

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