A nurse is admitting a term newborn 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
Absence of vitamin K
Maternal cocaine abuse
Physiologic jaundice
The Correct Answer is A
Choice A reason:
Maternal/newborn blood group incompatibility is the most common cause of pathologic jaundice, which appears within the first 24 hours of life. This occurs when the mother's antibodies attack the newborn's red blood cells, causing hemolysis and increased bilirubin production. The excess bilirubin causes the yellowish discoloration of the skin and mucous membranes.
Choice B reason:
The absence of vitamin K is not related to jaundice but to hemorrhagic disease of the newborn. Vitamin K is essential for blood clotting and is given to newborns as an injection shortly after birth. Newborns are at risk of vitamin K deficiency because they have low levels of vitamin K in their bodies and breast milk, and their intestinal bacteria are not yet able to synthesize vitamin K.
Choice C reason:
Maternal cocaine abuse can cause many complications for the newborn, such as prematurity, low birth weight, neonatal abstinence syndrome, neurobehavioral problems, and congenital anomalies. However, it is not a direct cause of jaundice in the newborn.
Choice D reason:
Physiologic jaundice is a normal and benign condition that affects about 60% of term newborns. It occurs due to the immature liver's inability to metabolize bilirubin effectively. It usually appears after the first 24 hours of life and peaks around the third or fourth day. It does not require treatment unless the bilirubin level is very high or rising rapidly.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason:
Monitoring the newborn's blood glucose level hourly is not necessary for a newborn undergoing phototherapy. Phototherapy does not affect blood glucose levels, and hourly monitoring would be too invasive and stressful for the newborn. •
Choice B reason:
Applying lotion to the newborn's skin twice per day is not recommended for a newborn undergoing phototherapy. Lotion can interfere with the effectiveness of the phototherapy and increase the risk of skin irritation or infection. •
Choice C reason:
Maintaining the newborn in a prone position is not advisable for a newborn undergoing phototherapy. The newborn should be positioned on alternate sides to expose as much skin surface as possible to the light source. •
Choice D reason:
Encouraging the newborn to breastfeed every 2 hr is an appropriate action for a newborn undergoing phototherapy. Frequent feeding helps to promote hydration and the elimination of bilirubin from the body.
Correct Answer is A
Explanation
Choice A reason:
Uterine atony is the failure of the uterus to contract and retract after delivery, which can lead to excessive bleeding and hemorrhage. It is the most common cause of postpartum hemorrhage, accounting for up to 80 percent of cases. Risk factors for uterine atony include large or multiple babies, prolonged or rapid labor, overdistended uterus, use of oxytocin or magnesium sulfate during labor, and previous history of uterine atony.
Choice B reason:
Puerperal infection is an infection of the reproductive tract that occurs within six weeks after delivery. It can affect the uterus (endometritis), the bladder (cystitis), the kidneys (pyelonephritis), the breast (mastitis), or the wound (cesarean section or episiotomy).
Symptoms include fever, chills, malaise, foul-smelling lochia, pelvic pain, and wound redness or drainage. Risk factors for puerperal infection include cesarean delivery, prolonged rupture of membranes, prolonged labor, multiple vaginal examinations, retained placental fragments, and poor hygiene.
Choice C reason:
Retained placental fragments are pieces of the placenta that remain in the uterus after delivery. They can cause postpartum hemorrhage, infection, or delayed involution of the uterus. Symptoms include heavy or prolonged bleeding, fever, abdominal pain, and an enlarged uterus. Risk factors for retained placental fragments include placenta previa, placenta accrete, manual removal of the placenta, and incomplete examination of the placenta after delivery.
Choice D reason:
Thrombophlebitis is the inflammation and clotting of a vein, usually in the legs or pelvis. It can cause pain, swelling, redness, and warmth in the affected area. It can also lead to pulmonary embolism if the clot breaks off and travels to the lungs. Risk factors for thrombophlebitis include pregnancy and the postpartum period, cesarean delivery, obesity, smoking, dehydration, immobility, varicose veins, and inherited or acquired clotting disorders.
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