pg. 1
,Respiratory findings is incorrect. The newborn's respiratory rate is within the expected reference range of 30
to 60/min. There is no indication the newborn has an alteration in respiratory status; therefore, this finding does
not need to be reported to the provider.
Temperature is incorrect. The newborn's temperature is within the expected reference range of 36.5° to 37.5° C
(97.7° to 99.5° F). Therefore, this finding does not need to be reported to the provider.
pg. 2
,Oxygen saturation is incorrect. The newborn's oxygen saturation is within the expected reference range of
greater than 94%; therefore, this finding does not need to be reported to the provider. Central nervous system
findings is correct. The newborn is displaying inconsolability, high-pitched cry, increased muscle tone, tremors,
hyperactive Moro reflex, and excessive sucking. These findings are manifestations of NAS and should be reported
to the provider.
Gastrointestinal findings is correct. The newborn is displaying poor feeding and loose stools. These findings
are manifestations of NAS and should be reported to the provider.
pg. 3
, When generating solutions, inserting a large bore intravenous catheter is indicated. Clients who have third
trimester vaginal bleeding may experience a sudden hemorrhage and require fluid resuscitation or the
administration of blood products. The nurse should weigh perineal pads. Weighing perineal pads after use will
provide a more accurate assessment of the volume of blood loss that the client is experiencing.
When generating solutions, the nurse should not administer methotrexate or assess for cervical dilation because it
is contraindicated for this client. Methotrexate is an antimetabolite and folic acid antagonist which destroys rapidly
pg. 4
,Respiratory findings is incorrect. The newborn's respiratory rate is within the expected reference range of 30
to 60/min. There is no indication the newborn has an alteration in respiratory status; therefore, this finding does
not need to be reported to the provider.
Temperature is incorrect. The newborn's temperature is within the expected reference range of 36.5° to 37.5° C
(97.7° to 99.5° F). Therefore, this finding does not need to be reported to the provider.
pg. 2
,Oxygen saturation is incorrect. The newborn's oxygen saturation is within the expected reference range of
greater than 94%; therefore, this finding does not need to be reported to the provider. Central nervous system
findings is correct. The newborn is displaying inconsolability, high-pitched cry, increased muscle tone, tremors,
hyperactive Moro reflex, and excessive sucking. These findings are manifestations of NAS and should be reported
to the provider.
Gastrointestinal findings is correct. The newborn is displaying poor feeding and loose stools. These findings
are manifestations of NAS and should be reported to the provider.
pg. 3
, When generating solutions, inserting a large bore intravenous catheter is indicated. Clients who have third
trimester vaginal bleeding may experience a sudden hemorrhage and require fluid resuscitation or the
administration of blood products. The nurse should weigh perineal pads. Weighing perineal pads after use will
provide a more accurate assessment of the volume of blood loss that the client is experiencing.
When generating solutions, the nurse should not administer methotrexate or assess for cervical dilation because it
is contraindicated for this client. Methotrexate is an antimetabolite and folic acid antagonist which destroys rapidly
pg. 4
