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 A
Explanation
Choice A rationale
A respiratory rate of 10/min is concerning as it indicates possible respiratory depression, which can be a side effect of spinal anesthesia. This requires immediate intervention to
prevent hypoxia and other complications.
Choice B rationale
Blood pressure of 100/70 mm Hg is within normal limits and does not require immediate intervention in this context.
Choice C rationale
Urinary output of 30 ml/hr is slightly low, but it is not immediately life-threatening. It may require monitoring and further assessment if it persists.
Choice D rationale
A headache pain rated a 6 on a scale of 0 to 10 could indicate a post-dural puncture headache, which is common after spinal anesthesia. It requires attention but is not an immediate
life-threatening condition. .
Correct Answer is A
Explanation
Choice A rationale
Brisk patellar deep tendon reflexes can indicate central nervous system irritability, which might suggest conditions like preeclampsia or eclampsia if accompanied by other symptoms. It's critical to assess and monitor for further complications.
Choice B rationale
A moderate amount of lochia on the perineal pad over 2 hours is normal postpartum bleeding and does not typically indicate an immediate concern if within expected ranges.
Choice C rationale
A fundus at the level of the umbilicus is an expected finding 4 hours postpartum and indicates normal uterine involution. It is not a priority concern at this stage.
Choice D rationale
Approximated edges of an episiotomy indicate that the incision is healing properly without signs of infection or dehiscence. This is a normal and expected finding in the postpartum period.