A nurse is caring for a term newborn who is 48 hr old
The nurse assessing the newborn 24 hr later. How should the nurse interpret the findings?
For each finding, click to specify whether the finding is unrelated to the diagnosis, a sign of potential improvement, or a sign of potential worsening condition.
Transient strabismus
Respiratory rate 70/min
Continuous high-pitched cry
Regurgitation
Loose stools
The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"C"},"C":{"answers":"C"},"D":{"answers":"A"},"E":{"answers":"A"}}
Transient strabismus:
Interpretation: Unrelated to diagnosis
Explanation: Transient strabismus (crossed eyes) is not necessarily related to the maternal history of opioid use or precipitous birth. It is a common finding in newborns and often resolves on its own without intervention.
Respiratory rate 70/min:
Interpretation: Sign of potential worsening condition
Explanation: A respiratory rate of 70/min in a newborn is higher than the normal range (30-60 breaths per minute). This could indicate respiratory distress, infection, or other complications, requiring further assessment.
Continuous high-pitched cry:
Interpretation: Sign of potential worsening condition
Explanation: A continuous high-pitched cry can be a sign of potential distress or discomfort in a newborn. It may be associated with various conditions, including withdrawal symptoms related to maternal opioid use during pregnancy. This finding warrants further assessment.
Regurgitation:
Interpretation: Unrelated to diagnosis
Explanation: Regurgitation (spitting up) is a common occurrence in newborns and is not necessarily related to the maternal history of opioid use. It is often a normal physiological process in infants.
Loose stools:
Interpretation: Unrelated to diagnosis
Explanation: Loose stools can be a normal finding in newborns and may not be directly related to the maternal history of opioid use. It is not necessarily indicative of a worsening condition in this context.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. I will receive a series of three immunizations, and each one will be a month apart: This statement is not accurate for rubella immunization. The MMR vaccine is usually administered as a single injection.
B. I should avoid becoming pregnant for at least 1 month following the immunization
Rubella immunization is typically administered as the measles, mumps, and rubella (MMR) vaccine. The statement indicating understanding reflects awareness of the importance of avoiding pregnancy for a certain period after receiving the rubella immunization due to potential risks to the developing fetus.
C. I should avoid breastfeeding for 2 weeks following the immunization: Breastfeeding is not a contraindication after receiving the rubella immunization. In fact, breastfeeding is generally not affected, and mothers can continue to breastfeed.
D. I will report joint pain that develops after the immunization to my provider immediately: Joint pain is a potential side effect of the rubella vaccine. Reporting joint pain to the provider is essential for monitoring and addressing any adverse reactions.
Correct Answer is B
Explanation
a: The diaphragm should be used with a spermicide, not a vaginal lubricant. Spermicide is necessary to kill sperm and increase the effectiveness of the diaphragm.
b: The diaphragm can be inserted up to 6 hours before intercourse, making it a convenient option for contraception. It should be left in place for at least 6 hours after intercourse but not more than 24 hours to ensure effectiveness.
c: The diaphragm should not be removed 2 to 4 hours after intercourse. It must remain in place for at least 6 hours after intercourse to provide effective contraception.
d:Washing the diaphragm with detergent soap can damage the latex and increase the risk of deterioration. It should be washed with mild soap and water or with a special cleanser recommended by the healthcare provider.
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