A nurse is caring for a newborn client. The assessment findings include a high-pitched cry, increased muscle tone, frequent yawning, poor feeding with projectile vomiting, and tachypnea.
What condition does the nurse suspect?
Hyperbilirubinemia.
Neonatal abstinence syndrome.
Respiratory distress syndrome.
Necrotizing enterocolitis.
Necrotizing enterocolitis.
The Correct Answer is B
Choice A rationale
Hyperbilirubinemia presents with jaundice (yellowing of the skin and eyes) and is caused by excess bilirubin in the blood. It doesn't typically involve a high-pitched cry, increased
muscle tone, or projectile vomiting.
Choice B rationale
Neonatal abstinence syndrome occurs in newborns exposed to addictive opiate drugs while in the mother’s womb. Symptoms include high-pitched crying, increased muscle tone,
yawning, poor feeding with vomiting, and tachypnea due to drug withdrawal.
Choice C rationale
Respiratory distress syndrome is primarily characterized by breathing difficulties, including rapid, shallow breathing and a grunting sound. Symptoms do not typically include high-
pitched cry or projectile vomiting.
Choice D rationale
Necrotizing enterocolitis involves severe inflammation and necrosis of the intestines. Symptoms include abdominal distension, vomiting bile, bloody stools, and apnea but not a high-
pitched cry or increased muscle tone.
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Correct Answer is ["B","D","F"]
Explanation
Choice A rationale:
Supplementing with formula is not necessary based on the given information. The baby is voiding and passing stools adequately, indicating proper feeding. Instead, feeding on demand and ensuring frequent breastfeeding will help address any concerns about the baby's weight.
Choice B rationale:
Feeding 8 to 12 times per day and on demand is recommended to ensure adequate milk supply and proper growth and development of the newborn. Frequent feeding helps to establish and maintain milk production.
Choice C rationale:
Using plastic-lined breast pads is not recommended as they can trap moisture and create an environment that promotes nipple irritation and infection. It is better to use breathable, non-plastic-lined breast pads.
Choice D rationale:
It is correct that a newborn's stools should transition from the dark greenish color meconium to a yellow color within a few days as the baby begins digesting breast milk.
Choice E rationale:
Drinking more whole milk does not directly increase a mother's milk supply. Milk supply is primarily regulated by the frequency and efficiency of breastfeeding or pumping.
Choice F rationale:
Expecting the breasts to feel full, warm, and slightly tender when the milk comes in is accurate. This usually occurs around the third or fourth day postpartum and indicates that the milk production process is underway.
Correct Answer is C
Explanation
Choice A rationale
Placenta formation begins shortly after implantation, but it continues to develop throughout the first trimester and into the early second trimester, making it less precise to attribute the
first 8 weeks solely to this process.
Choice B rationale
Fertilization occurs within the first week after ovulation, marking the beginning of pregnancy, but it is a singular event that happens prior to the developmental processes vulnerable to teratogens.
Choice C rationale
Organogenesis is the critical period during which the major organs and structures of the fetus form, typically occurring between the third and eighth weeks of gestation. This is the
time when the fetus is most susceptible to the effects of teratogens, which can cause congenital anomalies.
Choice D rationale
Implantation occurs approximately 6-10 days after fertilization, embedding the blastocyst into the uterine lining. While crucial, it is not the primary period when teratogenic effects are
most significant, as this happens during organogenesis.