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

Administering oxygen via face mask is a common intervention for many complications during labor. However, it is not the first-line intervention for late decelerations. Late decelerations are a sign of fetal distress, often due to uteroplacental insufficiency. While oxygen can help increase oxygenation to the fetus, it does not address the root cause of the problem.

Choice B rationale

Elevating the patient’s legs is not typically the priority action when late decelerations are noted. This action would not alleviate the cause of late decelerations.

Choice C rationale

Having the patient turn to a side-lying position is often the first intervention when late decelerations are noted. This position helps increase blood flow to the placenta, potentially alleviating uteroplacental insufficiency and improving fetal oxygenation.

Choice D rationale

Increasing the infusion rate of IV fluids is not the first-line intervention for late decelerations. While it may be part of the management plan, it is not the priority action.

A. Call the family and ask them to stay with the client B. Apply wrist and leg restraints to the client C. Administer medication to sedate the client D. Move the client to a room closer to the nurses’ station

Correct Answer is D

Explanation

Choice D rationale

Moving the client to a room closer to the nurses’ station is an appropriate action to address the safety needs of an older adult client who is becoming increasingly restless and intermittently confused. This allows for closer observation and quicker intervention if needed.

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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 nurse is providing care for a patient who is in active labor and recognizes late decelerations on the fetal monitor.The healthcare provider has been informed.What is the nurse’s priority action?

Correct Answer is C

Explanation

A nurse is caring for an older adult client who was alert and oriented at admission, but now seems increasingly restless and intermittently confused.Which of the following actions should the nurse take to address the client’s safety needs?

Correct Answer is D

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?