A nurse is admitting a term newborn following a cesarean birth. The nurse observes that the newborn's skin is slightly yellow right after birth. This finding indicates the newborn is experiencing a complication related to which of the following?
Physiological jaundice
Maternal cocaine abuse
Maternal/newborn blood group incompatibility
Absence of vitamin K
The Correct Answer is C
Choice A reason: Physiological jaundice is not the correct answer, as it is a normal and benign condition that occurs in about 60% of term newborns, and usually appears after the first 24 hours of life. Physiological jaundice is caused by the breakdown of fetal hemoglobin and the immature liver function, and resolves within a few days.
Choice B reason: Maternal cocaine abuse is not the correct answer, as it is a maternal risk factor that can cause various complications in the newborn, such as low birth weight, prematurity, intrauterine growth restriction, or congenital anomalies. Maternal cocaine abuse does not cause jaundice in the newborn, unless it leads to hepatic or renal dysfunction.
Choice C reason: Maternal/newborn blood group incompatibility is the correct answer, as it is a maternal-fetal condition that can cause hemolytic disease of the newborn, which is a severe form of jaundice that can appear within the first 24 hours of life. Maternal/newborn blood group incompatibility occurs when the mother's blood type is Rh negative and the newborn's blood type is Rh positive, or when the mother's blood type is O and the newborn's blood type is A or B. The maternal antibodies cross the placenta and attack the newborn's red blood cells, causing hemolysis, anemia, and hyperbilirubinemia.
Choice D reason: Absence of vitamin K is not the correct answer, as it is a nutritional deficiency that can cause hemorrhagic disease of the newborn, which is a bleeding disorder that can occur within the first week of life. Absence of vitamin K is due to the lack of intestinal flora and the low vitamin K content in breast milk, and can cause bleeding in the skin, mucous membranes, or internal organs. Absence of vitamin K does not cause jaundice in the newborn, unless it leads to hepatic or biliary dysfunction.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Respiratory rate is the priority nursing assessment for this client, because magnesium sulfate can cause respiratory depression, which is a life-threatening complication. The nurse should monitor the client's respiratory rate closely, and discontinue the infusion if it falls below 12 breaths per minute.
Choice B reason: Bowel sounds is not a priority nursing assessment for this client, because magnesium sulfate does not have a significant effect on the gastrointestinal system. The nurse should assess the client's bowel sounds as part of the routine physical examination, but it is not a critical parameter for this medication.
Choice C reason: Time of last food intake is not a priority nursing assessment for this client, because magnesium sulfate does not interact with food or affect the absorption of nutrients. The nurse should inquire about the client's dietary intake and preferences, but it is not a vital factor for this medication.
Choice D reason: Temperature is not a priority nursing assessment for this client, because magnesium sulfate does not cause fever or hypothermia. The nurse should measure the client's temperature as part of the vital signs, but it is not a key indicator for this medication.
Correct Answer is B
Explanation
The correct answer is B. No special treatment is necessary.
Choice A reason: Prone positioning is not typically recommended for a fractured clavicle in infants. It does not facilitate bone alignment in the case of clavicle fractures and is not part of standard care.
Choice B reason: This is the correct choice because clavicle fractures in newborns generally heal on their own without the need for special treatment. Parents may be instructed to pin the child’s sleeve to the front of their clothing to avoid moving the arm while it heals, but beyond gentle handling, no other special treatment is necessary. In most cases, clavicle fractures in newborns heal very quickly without any problems, and usually, no treatment is required.
Choice C reason: Immobilization and casting are not standard care for newborn clavicle fractures. These fractures typically heal without such interventions, and immobilization with a cast is not needed for these types of injuries in infants.
Choice D reason: While range-of-motion exercises might be beneficial later in the healing process, they are not the primary consideration immediately after the fracture occurs. The initial care plan focuses on gentle handling and comfort for the infant, not on exercises.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.