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 ["C","E"]
Explanation
A nurse is preparing to examine a post-term newborn immediately following delivery. Which of the following findings should she expect to observe? (Select all that apply.) The correct answers are choices C and E: Cracked, peeling skin and Vernix in the folds and creases.
Choice A rationale:
The Moro reflex is a normal neonatal reflex that can be observed in newborns at term or preterm, not specifically in post-term newborns. It is characterized by the baby's response to a sudden loss of support, which causes them to startle, throw their arms out, and cry. This reflex is not unique to post-term newborns.
Choice B rationale:
The heel to ear maneuverability is not a typical finding in newborn assessments. It is not related to the term or post-term status of the newborn. Therefore, this choice is not applicable.
Choice C rationale:
Cracked, peeling skin is a common finding in post-term newborns. Post-term babies have been in the womb for a longer duration, which can lead to changes in the condition of their skin, including peeling and cracking. This is due to prolonged exposure to amniotic fluid and the protective vernix diminishing.
Choice D rationale:
Abundant lanugo is more commonly found in preterm or premature newborns. As babies approach their due date and beyond, they tend to shed this fine, downy hair. Therefore, this choice is not applicable to post-term newborns.
Choice E rationale:
Vernix in the folds and creases is a characteristic finding in post-term newborns. Vernix is a white, waxy substance that coats the skin of newborns. In post-term babies, this vernix may be found in the folds and creases of their skin, as they have had more time in the womb for it to accumulate.
Correct Answer is A
Explanation
The correct answer is choicea. “I should stimulate my nipples by squeezing softly.”
Choice A rationale:
Stimulating the nipples by squeezing them can encourage milk production, which is not recommended for a client who is bottle feeding and trying to reduce breast engorgement.
Choice B rationale:
Applying ice packs to the breasts can help reduce swelling and provide relief from engorgement.
Choice C rationale:
Wearing a snug-fitting bra can help support the breasts and reduce discomfort associated with engorgement.
Choice D rationale:
Placing crushed cabbage leaves on the breasts is a common home remedy that can help reduce swelling and discomfort from engorgement.
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