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:
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A nurse is assisting with the admission of a client who is in preterm labor at 30 weeks of gestation and has a new prescription for betamethasone. Which of the following statements should the nurse make? The correct answer is Choice A: "The purpose of this medication is to boost fetal lung maturity.”.
Choice A rationale:
Betamethasone is a corticosteroid given to pregnant women at risk of preterm delivery to accelerate fetal lung maturation. It promotes the production of surfactant in the fetal lungs, which is essential for preventing respiratory distress syndrome in preterm infants. This statement provides accurate information about the medication's purpose.
Choice B rationale:
Stating that the medication is for stopping preterm labor contractions is incorrect. Betamethasone is not a tocolytic agent used to halt contractions. It is solely administered to enhance fetal lung maturity and has no direct effect on uterine contractions.
Choice C rationale:
Indicating that the medication's purpose is to increase the fetal heart rate is inaccurate. Betamethasone does not affect fetal heart rate. Its primary role is to enhance the development of the fetal lungs to improve the newborn's respiratory function.
Choice D rationale:
Mentioning that the medication is to halt cervical dilation is not correct. Betamethasone is not intended to stop cervical dilation or prevent preterm labor. Its primary function is to prepare the fetal lungs for better functioning after birth.
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.
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