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 C
Explanation
Choice A rationale
While it’s true that any internal examination carries a risk of introducing infection, this is not the primary reason to avoid an internal examination in a client with placenta previa.
Choice B rationale
Initiating preterm labor is a concern with any internal examination, but it’s not the primary reason to avoid an internal examination in a client with placenta previa.
Choice C rationale
This is the correct answer. In a client with placenta previa, an internal examination could disturb the placenta and cause severe, potentially life-threatening bleeding.
Choice D rationale
While rupture of the membranes is a risk associated with internal examinations, it’s not the primary reason to avoid an internal examination in a client with placenta previa.
Correct Answer is A
Explanation
Choice A rationale
Rh(D) immunoglobulin prevents the formation of Rh antibodies in mothers who are Rh negative. If an Rh-negative mother is exposed to Rh-positive blood, as can happen during pregnancy or childbirth, her immune system may respond by making antibodies against the Rh antigen. This can cause problems in future pregnancies if the baby is Rh positive. Rh(D) immunoglobulin works by preventing the mother’s immune system from recognizing the Rh antigen, thus preventing the formation of antibodies.
Choice B rationale
Rh(D) immunoglobulin does not destroy Rh antibodies in mothers who are Rh negative. Once antibodies have formed, they cannot be destroyed by Rh(D) immunoglobulin.
Choice C rationale
Rh(D) immunoglobulin does not prevent the formation of Rh antibodies in newborns who are Rh positive. The purpose of Rh(D) immunoglobulin is to prevent the mother from forming Rh antibodies.
Choice D rationale
Rh(D) immunoglobulin does not destroy Rh antibodies in newborns who are Rh positive. The purpose of Rh(D) immunoglobulin is to prevent the mother from forming Rh antibodies.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.