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A nurse is caring for a term newborn male client who is 72 hours old in the neonatal intensive care unit. The newborn was born after a precipitous vaginal birth at 39 weeks of gestation. The mother has a history of opioid use during pregnancy.
Exhibits
The nurse is assessing the newborn 24 hours later. For each finding, specify whether the finding is unrelated to the diagnosis, a sign of potential improvement, or a sign of potential worsening condition.

A.

Regurgitation

B.

Transient strabismus

C.

Mottling

D.

Respiratory rate 70/min

E.

Continuous high-pitched cry

Answer and Explanation

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

•    Regurgitation: This could be a sign of potential worsening condition as it might indicate gastrointestinal issues, which can be a symptom of Neonatal Abstinence Syndrome (NAS).
•    Transient strabismus: This is unrelated to the diagnosis. Strabismus is common in newborns and usually resolves on its own within the first few months of life.
•    Mottling: This could be a sign of potential worsening condition. Mottling (a lacy pattern of dilated blood vessels under the skin) can be a sign of distress in a newborn.
•    Respiratory rate 70/min: This could be a sign of potential worsening condition. A respiratory rate of 70/min is higher than the normal range (30-60 breaths per minute) for a newborn, indicating possible respiratory distress.
•    Continuous high-pitched cry: This could be a sign of potential worsening condition. A high-pitched cry is a common symptom of NAS.
•    Loose stools: This could be a sign of potential worsening condition. Loose stools can be a symptom of NAS.
 


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Related Questions

Correct Answer is C

Explanation

Choice A rationale
Airborne precautions are used for diseases that are spread through tiny droplets in the air, such as tuberculosis or chickenpox. Clostridium difficile is not spread in this manner.
Choice B rationale

Droplet precautions are used for diseases that are spread through larger droplets, such as influenza or pertussis. Clostridium difficile is not spread in this manner.
Choice C rationale
This is the correct answer. Contact precautions are used for diseases that are spread through direct contact with the patient or their environment. Clostridium difficile is a bacterium that can be present in feces and can contaminate surfaces, so contact precautions are appropriate.
Choice D rationale
Protective environment precautions are used for patients who have a compromised immune system, such as those undergoing stem cell transplants. These precautions are not typically used for patients with Clostridium difficile.

Correct Answer is []

Explanation

Condition: The client is most likely expeíiencing Placenta píevia. This condition is chaíacteíized by painless, bíight íed vaginal bleeding duíing the thiíd tíimesteí, which matches the client’s symptoms.
Actions:

1. Instíuct the client to maintain bed íest: This can help to píevent fuítheí bleeding.
2. Píepaíe the client foí a possible ultíasound: An ultíasound can help to confiím the diagnosis and assess the placental location and fetal well-being.

Paíameteís to Monitoí:

1. Ïetal heaít íate: Monitoíing the fetal heaít íate can help to assess the baby’s well-being.
2. Hemoglobin and hematocíit levels: These should be monitoíed to assess the client’s blood loss and íisk of anemia.

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