A nurse is caring for a term newborn who is 48 hr old.

Physical Examination

High-pitched cry

Mild tremors when disturbed Increased muscle tone Sneezing six times within 1 hr Excessive sucking

Color: Consistent with genetic background Excoriation of the chin

Watery stools Projectile vomiting

Hyperactive Moro reflex

The nurse is 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.

Regurgitation

Mottling

Transient strabismus

Continuous high-pitched cry

Respiratory rate 70/min

Loose stools

Answer and Explanation

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

Regurgitation: Sign of Potential Worsening Condition - Regurgitation may indicate a feeding problem or gastrointestinal issue, which could worsen if not addressed.

Mottling: Sign of Potential Worsening Condition - Mottling can be a sign of poor perfusion or circulation, indicating potential worsening of the newborn's condition.

Transient strabismus: Sign of Potential Improvement - Transient strabismus, or crossed eyes, is common in newborns and often resolves on its own, indicating potential improvement.

Continuous high-pitched cry: Sign of Potential Worsening Condition - Continuous high- pitched crying may indicate discomfort or underlying pathology, suggesting potential worsening. Respiratory rate 70/min: Sign of Potential Worsening Condition - An increased respiratory rate may indicate respiratory distress or another issue, suggesting potential worsening.

Loose stools: Sign of Potential Worsening Condition - Loose stools in a newborn can be a sign of gastrointestinal upset or infection, indicating potential worsening of the newborn's condition.

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Free Nursing Study Resources

Correct Answer is ["A","C","E","F","G"]

Explanation

Rationale:

A. Newborns with neonatal abstinence syndrome (NAS) are often irritable and hypersensitive to stimuli. Keeping the environment calm and quiet can help minimize their discomfort.

B. Naloxone is not routinely used in the management of NAS unless there is evidence of severe respiratory depression or opioid overdose, which is not indicated in this scenario.

C. Maternal opioid use and positive urine drug screens for methadone may contraindicate breastfeeding due to the potential transmission of opioids to the infant through breast milk. It's essential to consult with healthcare providers regarding the safest feeding option for the newborn.

D. Eye contact during feeding is essential for bonding between the parent and the newborn and should not be discouraged unless medically necessary.

E. Ballard newborn screening helps assess the newborn's gestational age and guide appropriate care for neonates with NAS, as they may require specialized management.

F. Daily weighing helps monitor the newborn's hydration status and overall well-being, which is crucial in managing NAS and ensuring adequate nutrition.

G. Swaddling can provide comfort to newborns with NAS by mimicking the womb environment and reducing their agitation.

A. "The car seat should be positioned in the car at a 45-degree angle." B. "My baby will need a car seat challenge test before discharge." C. "When my baby is 1 year old, I can turn their car seat facing forward." D. "I can use a sleep sack to keep my baby warm in the car seat."

Correct Answer is A

Explanation

A. Positioning the car seat at a 45-degree angle helps to ensure that the baby's airway remains open and reduces the risk of slumping, which can lead to suffocation. This positioning is essential for newborns who may have limited head and neck control.

B. A car seat challenge test is typically performed for preterm infants or those with specific health concerns, not for all newborns. Newborns delivered at 38 weeks generally do not require this test unless there are other complications.

C. Car seat safety guidelines recommend that infants remain in a rear-facing position until at least 2 years of age, not just until they turn 1 year old. This statement does not demonstrate an understanding of current safety recommendations.

D. While sleep sacks can help keep a baby warm, they should not be used in a way that compromises the harness system of the car seat. It’s crucial to ensure that the baby is snugly secured in the car seat without any additional bulky clothing or blankets that could interfere with the safety harness.

In summary, the correct understanding is that the car seat should be positioned at a 45-degree angle for optimal safety.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["A","C","E","F","G"]

Explanation

A nurse is teaching about car seat safety to the parents of a newborn who was delivered at 38 weeks of gestation. Which of the following statements by a parent indicates an understanding of the teaching?

Correct Answer is A

Explanation

A nurse is assessing a client who is 3 days postpartum. Which of the following findings should the nurse report to the provider?

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