A patient's newborn is neurologically impaired. The most important nursing action should be:

Correct Answer: A

Rationale: In the context of maternal and newborn nursing, when a newborn is diagnosed with neurological impairment, the most important nursing action is to assist the patient and her family with the grieving process (option A). This is crucial because receiving such news can be emotionally overwhelming for the family, and they need support to cope with the situation. By providing emotional support, the nurse can help the family navigate their feelings, understand the implications of the diagnosis, and begin the process of acceptance and adjustment to the new reality. Performing neurological assessments of the newborn every four hours (option B) is important for monitoring the newborn's health status, but it is not the most critical immediate action in this situation. While ongoing assessments are necessary for appropriate care, addressing the emotional needs of the family takes precedence. Arranging for social services to discuss possible placement of the newborn (option C) is premature at this stage. The focus should be on providing emotional support to the family and facilitating their understanding of the situation before discussing long-term care options. Obtaining an order for an antidepressant to help the patient cope with the news (option D) may be necessary in some cases to support the mother's mental health, but it should not be the initial or most important nursing action. Emotional support and guidance in the grieving process are fundamental before considering pharmacological interventions. In the educational context, this scenario highlights the importance of holistic nursing care that addresses not only the physical needs of the newborn but also the emotional and psychological needs of the family. It underscores the significance of effective communication, empathy, and support in helping patients and families navigate challenging healthcare situations.

Correct Answer: D

Rationale: In maternal and newborn nursing, understanding neonatal weight loss in the first few days of life is crucial for providing appropriate care and education to new mothers. The correct answer, option D, "Excretion of fluid via lungs, urinary bladder, and bowels," is the most common reason for neonatal weight loss in the initial days after birth. This weight loss occurs as newborns transition from receiving nutrients intravenously in the womb to feeding orally. They excrete excess fluid through respiration, urine, and stool, leading to a decrease in weight. Option A, "Allergy to formula," is incorrect because neonatal weight loss in the first few days is generally not related to allergies, especially since newborns are not typically introduced to formula immediately after birth. Option B, "a hypoglycemic response," is also incorrect as neonatal weight loss is not primarily due to low blood sugar levels in the first 3 days but rather fluid excretion. Option C, "Inadequate breast or formula feeding," is not the main reason for initial neonatal weight loss as newborns naturally lose some weight as they adjust to feeding and excreting. Educationally, it is important for nurses to teach new mothers about the physiological processes influencing neonatal weight loss to alleviate their concerns and ensure they understand the normal course of newborn development. By explaining that initial weight loss is primarily due to fluid shifts and excretion, nurses can empower mothers to continue feeding their newborns as recommended without unnecessary worry about weight fluctuations. This knowledge also helps nurses identify abnormal weight loss patterns that may require further evaluation and intervention.

Correct Answer: C

Rationale: The correct answer is C) Hypoglycemia. In newborns of mothers with diabetes, there is a risk of hypoglycemia due to the sudden cessation of the maternal glucose supply post-birth. The symptoms described – jitteriness, weak cry, high-pitched cry, and irregular respirations – are classic signs of hypoglycemia in neonates. Option A) Hypovolemia is unlikely in this scenario as there are no signs of volume depletion such as poor perfusion or tachycardia. Option B) Hypocalcemia typically presents with symptoms like seizures, not jitteriness and weak cry. Option D) Hyperglycemia would not cause these specific symptoms; instead, it might lead to lethargy or poor feeding. Educationally, it is crucial for nurses in maternal and newborn care to understand the unique risks faced by infants of diabetic mothers, such as hypoglycemia, and to be able to recognize and manage these conditions promptly to prevent potential complications like seizures or long-term neurological issues. Early detection and intervention are key in ensuring the well-being of these newborns.

Correct Answer: D

Rationale: In the assessment of a newborn, the most important finding to report is a breathing pattern that is diaphragmatic with sternal retractions (Option D). This indicates respiratory distress, which can be a critical issue in a newborn and requires immediate attention to ensure adequate oxygenation. Diaphragmatic breathing and sternal retractions suggest increased work of breathing and potential respiratory compromise, making it crucial to notify the healthcare team promptly. Option A, a temperature of 97.7 degrees Fahrenheit, falls within the normal range for a newborn and may not require immediate reporting. Option B, a pale pink, rust-colored stain in the diaper, could indicate urate crystals or mild dehydration, which are common in newborns and usually resolve without intervention. Option C, a heart rate dropping to 120 beats/min, while slightly lower than the normal range for a newborn, may not be as concerning as respiratory distress. In an educational context, understanding the significance of different assessment findings in newborns is crucial for nurses working in maternal and newborn care. Recognizing signs of respiratory distress and knowing when to escalate care is essential to ensure the well-being of the newborn. This question highlights the importance of thorough assessment skills and prompt reporting of critical findings in neonatal care.

Correct Answer: A

Rationale: In this scenario, the highest priority health outcome for the neonate born at 34 weeks' gestation with the given vital signs is option A) Oxygenation will remain adequate. Adequate oxygenation is crucial for a premature infant as they are at higher risk of respiratory distress syndrome due to immature lungs. Option B) Body temperature will remain stable is important but secondary to oxygenation as hypothermia can be managed more easily than respiratory distress in a newborn. Option C) Weight will increase by 30g per day is important for overall growth but is not the immediate priority when the infant is at risk of respiratory compromise. Option D) Heart rate will recover to an acceptable range is significant but is usually a result of addressing the primary concern of oxygenation first. Educationally, this question highlights the importance of understanding the priorities in caring for a neonate, especially a preterm infant, and the critical nature of maintaining adequate oxygenation for their well-being and survival. It emphasizes the need for nurses to prioritize interventions based on the most urgent needs of the patient to ensure positive health outcomes.