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 B
Explanation
Choice A rationale
Repaglinide is an oral medication used to control blood sugar in people with type 2 diabetes, but it is not typically used in pregnancy.
Choice B rationale
Insulin is the most common medication used to control blood sugar in pregnant women with gestational diabetes when diet and exercise are not enough.
Choice C rationale
Acarbose is an oral medication used to control blood sugar in people with type 2 diabetes, but it is not typically used in pregnancy.
Choice D rationale
Glipizide is an oral medication used to control blood sugar in people with type 2 diabetes, but it is not typically used in pregnancy.
Correct Answer is A
Explanation
Choice A rationale
The client’s symptoms and lab results are consistent with HELLP Syndrome, a severe form of preeclampsia. HELLP stands for Hemolysis, Elevated Liver enzymes, and Low Platelet count. The client’s elevated liver enzymes and low platelets, along with the reported symptoms, are indicative of this condition.
Choice B rationale
While the client’s high blood pressure could suggest Postpartum hypertension, the presence of severe headaches, visual disturbances, right upper quadrant pain, and abnormal lab results point more towards HELLP Syndrome.
Choice C rationale
Hypertension in pregnancy could be a possibility, but it does not explain all of the client’s symptoms and lab results, particularly the elevated liver enzymes and low platelets.
Choice D rationale
Superimposed preeclampsia is a condition where a pregnant woman with chronic hypertension develops preeclampsia. However, the client’s severe symptoms and lab results are more indicative of HELLP Syndrome.
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