A nurse is caring for a newborn who is 70 hours old in the newborn nursery.
For each assessment finding, click to specify if the finding is consistent with hypoglycemia or neonatal abstinence syndrome (NAS). Each finding may support more than one disease process.
Temperature
Jitteriness
Skin color
Gastrointestinal (GI) assessment
The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A,B"},"C":{"answers":"B"},"D":{"answers":"B"}}
Rationales for Each Condition
Neonatal Abstinence Syndrome (NAS)
- Temperature: Infants experiencing NAS often have difficulty regulating body temperature due to autonomic instability. While the newborn's temperature of 36.6°C (97.9°F) is within normal range, the use of a radiant warmer suggests challenges in maintaining thermoregulation, which is characteristic of NAS.
- Jitteriness: Jitteriness is observed in both hypoglycemia and NAS. In NAS, it is caused by neurological excitability due to opioid withdrawal, leading to tremors and hypertonia, which improve with soothing measures such as swaddling.
- Skin Color: Mottling is a frequent sign in neonates experiencing opioid withdrawal due to autonomic dysregulation. The absence of cyanosis or jaundice indicates that the mottling is due to withdrawal rather than an underlying pathology.
- GI Assessment: Loose stools and hyperactive bowel sounds are typical signs of NAS, caused by increased gastrointestinal motility due to withdrawal from opioids.
Hypoglycemia
- Jitteriness: Hypoglycemia is characterized by neuromuscular instability, leading to jitteriness. However, in this case, the newborn’s blood glucose level of 45 mg/dL is within acceptable neonatal range, making NAS a more likely explanation.
- Temperature, Skin Color, and GI Assessment: Hypoglycemia does not typically cause mottled skin or loose stools, making these findings more consistent with NAS.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","E","F"]
Explanation
Choice A rationale
Hourly monitoring of deep tendon reflexes is crucial in clients receiving magnesium sulfate for severe preeclampsia. Magnesium sulfate acts as a central nervous system depressant, and diminished or absent deep tendon reflexes (normal range: 2+ to 4+) can indicate magnesium toxicity, necessitating immediate intervention to prevent serious complications like respiratory depression.
Choice B rationale
A urinary output of less than 30 mL per hour signals potential renal hypoperfusion, which can be exacerbated by severe preeclampsia and magnesium sulfate administration. Reduced kidney function can lead to the accumulation of magnesium, increasing the risk of toxicity. Prompt notification of the physician allows for timely adjustments in the treatment plan.
Choice C rationale
Calcium gluconate is the antidote for magnesium sulfate overdose. Having it readily available is essential in case the client exhibits signs of magnesium toxicity, such as respiratory depression, severe hypotension, or loss of reflexes. Prompt administration of calcium gluconate can reverse the effects of magnesium and prevent life-threatening complications.
Choice E rationale
Hourly monitoring of intake and output is vital to assess fluid balance and renal function in pregnant clients with severe preeclampsia receiving magnesium sulfate. Accurate measurement helps in detecting oliguria, a sign of worsening preeclampsia or magnesium toxicity, allowing for timely interventions to maintain adequate hydration and prevent complications.
Choice F rationale
Severe preeclampsia significantly impacts both renal and cardiac function due to widespread vasoconstriction and endothelial dysfunction. Close monitoring of these systems through laboratory tests (e.g., serum creatinine, BUN, electrolytes, ECG) and clinical assessments is essential to detect and manage potential complications such as acute kidney injury, heart failure, and arrhythmias.
Correct Answer is D
Explanation
Choice A rationale
A urinary output of 30 mL/hr is within the normal range for an adult, indicating adequate kidney perfusion and hydration status postpartum. Normal urine output is typically considered to be greater than 30 mL/hr.
Choice B rationale
Headache pain rated a 6 on a scale of 0 to 10 is a common complaint postpartum, especially after spinal anesthesia. While it requires assessment and management, it is not necessarily a sign of immediate life-threatening complication. Postpartum headaches can be related to hormonal shifts, dehydration, or the spinal anesthesia itself.
Choice C rationale
A blood pressure of 100/70 mm Hg is within the normal postpartum range for many women. While a decrease from pre-pregnancy levels can occur, this reading does not indicate an immediate critical issue. Normal postpartum blood pressure generally stabilizes around pre-pregnancy levels within a few days.
Choice D rationale
A respiratory rate of 10 breaths per minute is below the normal adult range of 12 to 20 breaths per minute. This bradypnea could indicate respiratory depression, a potential complication of spinal anesthesia, especially if opioid analgesics have been administered. Immediate intervention is required to assess the cause and ensure adequate oxygenation.
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