A nurse in the newborn unit is caring for several infants.
Which of the following situations requires the nurse's immediate attention and intervention?
A newborn who is 24 hours post-delivery and has not voided
A newborn who is 18 hours post-delivery and has acrocyanosis
A newborn who is 12 hours post-delivery and has a temperature of 37.5°C (99.5°F)
A newborn who is 24 hours post-delivery and has not passed meconium
The Correct Answer is D
Choice A rationale
A newborn typically begins to void within 24 hours after birth, so not voiding within this time frame is not immediately concerning.
Choice B rationale
Acrocyanosis, or bluish discoloration of the hands and feet, is common in newborns, especially within the first few hours after birth. It is a normal finding and does not require immediate intervention.
Choice C rationale
A temperature of 37.5°C (99.5°F) is within the normal range for a newborn. Therefore, this does not require immediate attention.
Choice D rationale
Newborns typically pass meconium, the first stool, within 24 to 48 hours after birth. If a newborn has not passed meconium within 24 hours, it could indicate a problem such as meconium ileus, a complication of cystic fibrosis, or other conditions that might obstruct the bowel. This situation requires immediate attention and intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Fetal hyperinsulinemia is a condition where the fetus produces an excess amount of insulin, and it is more commonly associated with macrosomia (large for gestational age) rather than being small for gestational age.
Choice B rationale
Preterm delivery can result in a baby being small for birth weight, but it does not cause a baby to be small for gestational age. Small for gestational age means the baby’s weight is less than the 10th percentile for their gestational age.
Choice C rationale
Perinatal asphyxia, a lack of oxygen before, during, or just after birth, does not cause a baby to be small for gestational age. It can cause other complications, such as organ damage.
Choice D rationale
Placental inefficiency, where the placenta does not work as well as it should, can cause a baby to be small for gestational age. This is because the baby may not receive enough oxygen and nutrients from the mother.
Correct Answer is A
Explanation
At the level of the umbilicus. After a vaginal delivery, the nurse should expect to find the uterine fundus at the level of the umbilicus.
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