Author Question: The pregnant woman has had no prenatal care and arrives at the hospital fully dilated. Assessment of ... (Read 163 times)

aabwk4 · **on:** Jun 28, 2018

The pregnant woman has had no prenatal care and arrives at the hospital fully dilated. Assessment of the newborn indicates a probable gestational age of 35 weeks combined with intrauterine growth restriction.

The nurse will monitor the infant for signs of neonatal abstinence syndrome, including: Standard Text: Select all that apply. 1. Poor feeding.
2. Difficult to arouse.
3. Constipation.
4. Seizures.
5. Yawning.

Question 2

A child is receiving chemotherapy induction for acute lymphocytic leukemia (ALL). Taking common side effects into consideration, which nursing diagnoses would be appropriate during the induction chemotherapy? Select all that apply.

1. Risk for infection
2. Skin Integrity: Impaired mucous membrane
3. Injury, risk for: hemorrhagic cystitis
4. Fluid and electrolyte Impairment: Nausea and vomiting
5. Impaired sleep pattern
6. Patterns of Elimination, Altered: diarrhea

kmb352 · **Reply #1 on:** Jun 28, 2018

Answer to Question 1

1,4,5
Rationale 1: This is a symptom of neonatal abstinence syndrome.
Rationale 2: These infants are usually restless and irritable, not sleepy.
Rationale 3: The infant is more likely to have diarrhea.
Rationale 4: Seizures are common in the child with neonatal abstinence syndrome.
Rationale 5: The infant with neonatal abstinence syndrome yawns frequently.
Global

Answer to Question 2

2, 3, 4, 6
Rationale:
1. Bone marrow suppression does not peak until 710 days post-induction. This nursing diagnosis would be appropriate at that time.
2. Mouth sores are a common early side effect of chemotherapy, and usually occur 25 days after the administration of chemotherapy.
3. Hemorrhagic cystitis is a common early side effect of chemotherapy, and is usually prevented with large amount of IV fluids to adequately protect the kidneys.
4. Nausea and vomiting are common early side effects of chemotherapy.
5. Impaired sleep patterns are not directly related to chemotherapy.
6. Diarrhea is a common early side effect of chemotherapy.