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 B
Explanation
A nurse is reinforcing nutritional teaching with a client who is at 8 weeks of gestation. Which of the following statements should the nurse include? The correct answer is choice B: "You should increase your folic acid intake during your pregnancy.”.
Choice A rationale:
"You should stop taking your prenatal vitamin if you experience nausea.”. This statement is incorrect. Nausea is a common symptom during pregnancy, especially during the first trimester. However, discontinuing prenatal vitamins is not recommended. It's essential to continue taking them to ensure the mother and baby receive adequate nutrients. Prenatal vitamins are designed to provide essential vitamins and minerals that are crucial for the baby's development. Discontinuing them due to nausea could lead to nutrient deficiencies.
Choice C rationale:
"You should limit your iron intake during your first trimester.”. This statement is incorrect. Iron intake should not be limited during the first trimester. Iron is an essential mineral during pregnancy, as the mother's blood volume increases, and iron is required to make more red blood cells to carry oxygen to the baby. Iron deficiency can lead to anemia, which can be harmful to both the mother and the baby. Therefore, iron intake is typically increased during pregnancy to meet the increased demand.
Choice D rationale:
"You should increase your daily calorie intake by 750 calories.”. This statement is not entirely accurate. While it's true that calorie needs increase during pregnancy, the recommended additional calorie intake is generally around 300-500 calories per day, not 750. The exact number can vary from person to person, depending on their pre-pregnancy weight and activity level. Consuming too many extra calories can lead to excessive weight gain, which can have negative consequences for both the mother and the baby. It's important to focus on the quality of calories consumed and ensure they come from nutrient-dense foods.
Correct Answer is D
Explanation
The correct answer is choice d. Use a postpartum depression-screening tool with the client.
Choice A rationale:
Arranging for counseling is important for long-term support, but the first step is to accurately assess the client’s condition using a screening tool.
Choice B rationale:
Requesting a prescription for an antidepressant may be necessary, but it should follow a proper assessment and diagnosis.
Choice C rationale:
Reinforcing teaching about rest and sleep is beneficial, but it does not address the immediate need to assess the severity of the client’s symptoms.
Choice D rationale:
Using a postpartum depression-screening tool is the first step to identify the severity of the client’s symptoms and determine the appropriate course of action.
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