A nurse is admitting a full-term baby boy delivered 12 hours ago to the nursery following a cesarean birth.
The nurse observes that the newborn's skin is slightly yellow.
This finding indicates the newborn is experiencing a complication related to which of the following?
Maternal/newborn blood group incompatibility.
Physiologic jaundice.
Maternal cocaine abuse.
Absence of vitamin K. .
The Correct Answer is B
Choice A rationale:
Maternal/newborn blood group incompatibility can lead to jaundice in newborns, but it typically occurs within the first 24 hours of life. In this scenario, the baby is delivered 12 hours ago, and the yellowing of the skin is described as "slight.”. Physiologic jaundice, which occurs in the majority of newborns, typically appears on the second or third day after birth, so this choice is less likely.
Choice B rationale:
Physiologic jaundice is the most likely cause of the slight yellowing of the newborn's skin. It typically appears on the second or third day after birth and is related to the immature liver's inability to efficiently process bilirubin. Physiologic jaundice is a common and self-limiting condition that does not usually require treatment.
Choice C rationale:
Maternal cocaine abuse can lead to various neonatal complications, but it is not typically associated with jaundice. The yellowing of the skin in this scenario is more likely related to another cause.
Choice D rationale:
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Calcium gluconate is the antidote for magnesium sulfate toxicity. Magnesium sulfate is commonly used to prevent seizures in clients with preeclampsia, but it can lead to respiratory depression and toxicity when levels become too high. Administering calcium gluconate helps counteract the effects of magnesium toxicity by competing for binding sites and restoring neuromuscular function. This is the appropriate treatment to address the client's symptoms of respiratory depression, which are suggestive of magnesium sulfate toxicity.
Choice B rationale:
Flumazenil is not the correct choice in this situation. Flumazenil is a medication used to reverse the effects of benzodiazepine overdose, not magnesium sulfate toxicity. It does not have any impact on magnesium levels or their associated toxic effects.
Choice C rationale:
Naloxone is used to reverse the effects of opioids, such as morphine or fentanyl. It is not indicated for magnesium sulfate toxicity. Administering naloxone would not address the client's symptoms or the underlying cause of respiratory depressionzz.
Choice D rationale:
Protamine sulfate is an antidote used to reverse the anticoagulant effects of heparin, not magnesium sulfate. It is not effective in treating magnesium sulfate toxicity. Administering protamine sulfate would not be the appropriate intervention for this situation.
Correct Answer is B
Explanation
To calculate the estimated date of delivery (EDD) using Naegele’s rule, the nurse would:
- Add one year to the year of the last menstrual period (LMP).
- Subtract three months from the month of the LMP.
- Add seven days to the day of the LMP.
Given the first day of the client’s last menstrual period was April 4, 2023:
- Adding one year: April 4, 2024
- Subtracting three months: January 4, 2024
- Adding seven days: January 11, 2024
So, the nurse should tell the client that her estimated date of delivery (EDD) isJanuary 11, 2024.
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