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 ["A","E"]
Explanation
Choice A rationale
A cesarean section will be necessary if vaginal lesions are present at the time of labor. This is to prevent the transmission of the herpes virus to the baby during delivery, which can lead to serious complications such as neonatal herpes, a potentially deadly infection.
Choice B rationale
While sitz baths can help alleviate the discomfort caused by genital herpes lesions, they do not directly protect the fetus from herpes infection. The primary purpose of sitz baths in this context is to provide symptomatic relief to the mother.
Choice C rationale
The newborn will not necessarily be observed and treated in the neonatal intensive care unit just because the mother has genital herpes. The need for neonatal intensive care would depend on various factors, including whether the baby contracts the virus during delivery.
Choice D rationale
Total abstinence from sexual intercourse is not necessary during the entire pregnancy. However, it is recommended to abstain from sexual intercourse during active outbreaks to reduce the risk of transmission.
Choice E rationale
Daily administration of Valacyclovir (Valtrex) is necessary after the 36th week of pregnancy. This is known as suppressive therapy, which can help reduce the risk of an outbreak at the time of delivery and thereby reduce the risk of transmitting the virus to the baby.
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.
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