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A nurse is assessing a newborn who has neonatal abstinence syndrome. Which of the following findings should the nurse expect?
- A. Diminished deep tendon reflexes
- B. Excessive crying
- C. Decreased muscle tone
- D. Absent Moro reflex
Correct Answer: B
Rationale: The correct answer is B: Excessive crying. Neonatal abstinence syndrome is characterized by withdrawal symptoms in newborns exposed to addictive substances in utero. Excessive crying is a common manifestation due to neurological irritability. Diminished deep tendon reflexes (A) would not be expected as the central nervous system is hyperactive. Decreased muscle tone (C) is unlikely as muscle rigidity or tremors are more common. Absent Moro reflex (D) is not typically seen as it is a primitive reflex present in newborns.
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Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
- A. Initiate anticoagulant therapy, Administer an oxytocic medication, Apply ice packs to the breasts.
- B. Engorgement, Urinary tract infection, Deed vein thrombosis
- C. Temperature, Circumference of lower extremities, Integrity of the nipples
Correct Answer:
Rationale: Correct Answer: Action to Take: A, B; Potential Condition: B; Parameter to Monitor: C, E.
Rationale:
1. Potential Condition: Engorgement is a common condition postpartum characterized by breast fullness and tenderness.
2. Actions to Take: Initiate anticoagulant therapy to prevent deep vein thrombosis and administer an oxytocic medication to relieve engorgement.
3. Parameters to Monitor: Circumference of lower extremities (for DVT) and integrity of the nipples (for engorgement). These parameters will help assess the client's progress in managing these conditions effectively.
A nurse is caring for a newborn who has jaundice and a new prescription for phototherapy. Which of the following actions should the nurse take?
- A. Provide the newborn with 15 mL glucose water after each feeding.
- B. Turn the newborn every 4 hr.
- C. Apply hydrating lotion to the newborn’s skin prior to treatment.
- D. Close the newborn's eyes before applying eyepatches.
Correct Answer: D
Rationale: The correct action is D: Close the newborn's eyes before applying eyepatches. This is crucial during phototherapy to protect the eyes from potential damage due to exposure to light. Closing the eyes with eyepatches helps prevent eye irritation and potential harm to the sensitive eye tissues. Providing glucose water (A) is not directly related to phototherapy. Turning the newborn (B) every 4 hours is important for general care but not specific to phototherapy. Applying hydrating lotion (C) is not necessary and may interfere with the effectiveness of the treatment.
A nurse is providing teaching to the parents of a newborn about the Plastibell circumcision technique. Which of the following information should the nurse include?
- A. The Plastibell will be removed 4 hours after the procedure.
- B. Make sure the newborn’s diaper is snug.
- C. Yellow exudate will form at the surgical site in 24 hours.
- D. Notify the provider if the end of your baby’s penis appears dark red.
Correct Answer: D
Rationale: The correct answer is D: Notify the provider if the end of your baby’s penis appears dark red. This is important to monitor for signs of infection, such as redness, swelling, or discharge. Yellow exudate forming in 24 hours (C) is incorrect as it may indicate infection. The Plastibell is typically removed after a few days, not 4 hours (A). Ensuring a snug diaper (B) is irrelevant to the circumcision technique.
A nurse is caring for a client who delivered by cesarean birth 6 hr ago. The nurse notes a steady trickle of vaginal bleeding that does not stop with fundal massage. Which of the following actions should the nurse take?
- A. Replace the surgical dressing.
- B. Evaluate urinary output.
- C. Apply an ice pack to the incision site.
- D. Administer 500 mL lactated Ringer’s IV bolus.
Correct Answer: D
Rationale: The correct answer is D: Administer 500 mL lactated Ringer’s IV bolus. This action is necessary to address the persistent vaginal bleeding after cesarean birth, as it could be a sign of postpartum hemorrhage. Administering IV fluids helps to improve circulating volume and maintain adequate perfusion to vital organs. This can help stabilize the client's condition while further assessments and interventions are carried out.
Choice A: Replacing the surgical dressing does not address the underlying cause of the bleeding and is not a priority at this time.
Choice B: Evaluating urinary output is important but not the immediate action needed to address the vaginal bleeding.
Choice C: Applying an ice pack to the incision site is not appropriate for controlling postpartum bleeding.
In summary, administering IV fluids is the priority to address potential postpartum hemorrhage, while the other options do not directly address the urgent issue at hand.
Select the 3 findings that require immediate follow-up.
- A. Lateral deviation of the uterus
- B. Deep tendon reflexes 1+
- C. Pain rating of 3 on a scale of 0 to 10 (increased)
- D. Peripheral edema 2+ bilateral lower extremities
- E. Uterine tone soft
- F. Large amount of lochia rubra
- G. Blood pressure 136/86 mm Hg
Correct Answer: A,B,C
Rationale: The correct choices for immediate follow-up are A, B, and C. A lateral deviation of the uterus could indicate a possible complication like uterine atony or retained products of conception. Deep tendon reflexes of 1+ could suggest hyporeflexia or neurological issues. A pain rating of 3 on a scale of 0 to 10, especially if it has increased, may indicate worsening pain or a new issue. Choices D, E, F, and G do not present immediate concerns that require urgent follow-up compared to choices A, B, and C. Peripheral edema 2+ in bilateral lower extremities, soft uterine tone, large amount of lochia rubra, and a blood pressure of 136/86 mm Hg are important findings but do not necessitate immediate intervention or follow-up.