Exhibits

Based on the information in the newborn's medical record, the nurse determines that the newborn is at risk for developing which of the following complications?

Hypoglycemia

Neonatal abstinence syndrome

Respiratory distress syndrome

Neonatal jaundice .

Answer and Explanation

The Correct Answer is B

Choice A rationale

Hypoglycemia, or low blood sugar, is a condition that can occur in newborns, especially those born to mothers with gestational diabetes. However, there is no information in the question indicating that the mother had gestational diabetes. Therefore, while hypoglycemia is a possible complication for newborns, it is not the most likely complication in this case based on the information provided.

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 occur when a pregnant woman takes drugs such as heroin, codeine, oxycodone (Oxycontin), methadone, or buprenorphine. These and other substances pass through the placenta that connects the baby to its mother in the womb and can cause the baby to become dependent on the drug. In this case, the mother’s urine toxicology screen was positive for cocaine and marijuana, both of which are illicit drugs. This puts the newborn at risk for developing NAS2.

Choice C rationale

Respiratory distress syndrome (RDS) is a breathing disorder that affects newborns. RDS is more common in premature babies because their lungs aren’t fully developed. However, the newborn in the question was born at 38 weeks gestation, which is considered full term. Therefore, while RDS is a possible complication for newborns, it is not the most likely complication in this case based on the information provided.

Choice D rationale

Neonatal jaundice is a condition that can occur in newborns due to high levels of bilirubin, a yellow pigment produced during normal breakdown of red blood cells. In older babies and adults, the liver processes bilirubin, which then passes from the body through the stool and urine. However, a newborn’s still-developing liver may not be mature enough to remove this bilirubin. While neonatal jaundice is a common condition, there is no information in the question indicating that the newborn is at risk for developing this complication.

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Correct Answer is C

Explanation

Choice A rationale

Waiting until the next appointment could potentially put both the mother and the baby at risk. Leakage of vaginal fluid could indicate premature rupture of membranes, which can lead to infection or premature labor.

Choice B rationale

While fetal movement is a good sign, it does not rule out potential complications associated with leakage of vaginal fluid. Therefore, this advice could lead to a delay in necessary medical intervention.

Choice C rationale

This is the most appropriate response. Leakage of vaginal fluid in a pregnant woman could be a sign of premature rupture of membranes, which can lead to complications such as infection or premature labor. Immediate medical attention is necessary to assess the situation and take appropriate action.

Choice D rationale

Asking the client to wait and see if the leakage changes could potentially delay necessary medical intervention. It’s important to seek immediate medical attention to assess the situation and take appropriate action.

A. Return the platelet bag and tubing to the blood bank. B. Stop the infusion. C. Notify the provider. D. Collect a urine sample from the client.

Correct Answer is B

Explanation

Choice A rationale

Returning the platelet bag and tubing to the blood bank is not the immediate action to take when a client reports having lower back pain and feeling chilled and itchy during a PRBC transfusion. These symptoms could indicate a transfusion reaction, which is a serious complication that requires immediate intervention.

Choice B rationale

Stopping the infusion is the first action the nurse should take when a client reports symptoms of a transfusion reaction. This is because continuing the transfusion could worsen the reaction and potentially lead to more serious complications.

Choice C rationale

While notifying the provider is an important step in managing a transfusion reaction, it is not the first action the nurse should take. The nurse should first stop the infusion to prevent further exposure to the blood product.

Choice D rationale

Collecting a urine sample from the client is not the immediate action to take when a client reports having lower back pain and feeling chilled and itchy during a PRBC transfusion. These symptoms could indicate a transfusion reaction, which requires immediate intervention.

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Exhibits Based on the information in the newborn's medical record, the nurse determines that the newborn is at risk for developing which of the following complications?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A 23 weeks pregnant client calls the clinic and reports leakage of vaginal fluid.What should be the appropriate response by the nurse?

Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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Exhibits

Based on the information in the newborn's medical record, the nurse determines that the newborn is at risk for developing which of the following complications?