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 A
Explanation
A. The client’s fundus is firm and midline: Oxytocin is commonly administered in the third stage of labor to promote uterine contraction and prevent postpartum hemorrhage. A therapeutic effect of oxytocin is the firm and midline positioning of the uterus, indicating effective contraction and the prevention of excessive bleeding.
B. The client’s umbilical cord lengthens: The lengthening of the umbilical cord is not an expected therapeutic effect of oxytocin administration. Oxytocin primarily affects uterine contractions.
C. The client reports a feeling of vaginal fullness: A feeling of vaginal fullness is not a typical therapeutic effect of oxytocin administration. It may be associated with other factors, such as the presence of blood clots or retained placental fragments, and should be further assessed.
D. The client saturates a perineal pad in 1 hour: Saturating a perineal pad in 1 hour is not an expected therapeutic effect of oxytocin. Excessive bleeding or saturation of perineal pads may be a sign of postpartum hemorrhage and requires immediate attention.
Correct Answer is B
Explanation
A. Hypertension: Hypertension is not typically associated with abruptio placentae. In fact, abruptio placentae is often linked to conditions such as chronic hypertension, but the presentation is more commonly associated with symptoms like uterine tenderness, bleeding, and fetal distress.
B. Uterine tenderness: This is the correct answer. Uterine tenderness is a common clinical finding in abruptio placentae. It results from the separation of the placenta from the uterine wall, leading to blood accumulation in the uterine musculature.
C. Leukorrhea: Leukorrhea, a white or yellowish discharge from the vagina, is not a typical finding in abruptio placentae. The condition is characterized by vaginal bleeding and uterine tenderness.
D. Fetal tachycardia: Fetal distress, including fetal tachycardia, is a potential complication of abruptio placentae. However, uterine tenderness is a more immediate and direct finding associated with the separation of the placenta.
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