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
Methylergonovine (Methergine) is contraindicated in clients with hypertension because it can cause severe hypertension by increasing vascular resistance, leading to potential complications such as stroke.
Choice B rationale
Oxytocin (Pitocin) is used to induce labor and control postpartum hemorrhage and does not significantly increase blood pressure, making it safe for use in hypertensive patients.
Choice C rationale
Carboprost (Hemabate) is used to control severe postpartum hemorrhage and does not have significant effects on blood pressure. It is generally safe for hypertensive patients.
Choice D rationale
Misoprostol (Cytotec) is used for postpartum hemorrhage management and does not significantly affect blood pressure, making it safe for hypertensive patients.
Correct Answer is B
Explanation
Choice A rationale
Turning the newborn's head quickly to one side elicits the tonic neck reflex, not the Moro reflex. The tonic neck reflex involves the newborn's arm extending on the side where the
head is turned and the opposite arm bending at the elbow, resembling a fencing position.
Choice B rationale
Performing a sharp hand clap near the infant elicits the Moro (startle) reflex, which is characterized by the infant throwing their arms outward, opening their hands, and then bringing
the arms back in. This is a response to sudden stimuli and is a normal reflex in newborns.
Choice C rationale
Stroking the outer edge of the sole of the foot from near the heel up toward the toes elicits the Babinski reflex, not the Moro reflex. The Babinski reflex is characterized by the big toe
moving upward or toward the top surface of the foot and the other toes fanning out.
Choice D rationale
Placing a finger at the base of the newborn's toes elicits the plantar grasp reflex, not the Moro reflex. The plantar grasp reflex involves the toes curling around the finger or object
placed at the base of the toes. .