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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?

A.

Hyperbilirubinemia.

B.

Neonatal abstinence syndrome.

C.

Respiratory distress syndrome.

D.

Necrotizing enterocolitis.

E.

Necrotizing enterocolitis.

Answer and Explanation

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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View Related questions

Correct Answer is A

Explanation

Choice A rationale

Betamethasone is a corticosteroid that accelerates fetal lung maturity by increasing the production of surfactant, which reduces respiratory distress syndrome in preterm infants.

Choice B rationale

While betamethasone can cause transient increases in fetal heart rate, its primary purpose is not to increase fetal heart rate. Its role is in enhancing lung maturity.

Choice C rationale

Betamethasone does not directly increase amniotic fluid levels. Its main function is in the maturation of fetal lungs.

Choice D rationale

Betamethasone is not used to stop preterm labor contractions. It is used to accelerate fetal lung development in preterm labor cases.

Correct Answer is A

Explanation

Choice A rationale

Administering antipyretics for maternal fever is essential as elevated maternal temperatures can increase the risk of fetal tachycardia and potentially lead to fetal distress. Reducing

fever promptly is a priority to stabilize both maternal and fetal conditions.

Choice B rationale

Preparing for an emergency cesarean section is not the immediate step for maternal fever; instead, managing the fever and assessing the need for further interventions based on the

overall clinical picture should be prioritized.

Choice C rationale

Administering glucocorticoids is indicated for promoting fetal lung maturity in preterm labor, not specifically for maternal fever management. Fever management requires antipyretics

and hydration.

Choice D rationale

Waiting 4 hours to recheck temperature delays prompt management, increasing risks for both the mother and fetus. Immediate action to reduce fever is crucial to prevent potential

complications.

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