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 ["C","D","F"]
Explanation
Choice A:
Temperature is not a finding that needs to be reported to the provider unless it is abnormally high or low. The normal temperature range for a newborn is 36.5°C to 37.5°C (97.7°F to 99.5°F).
Choice B:
Respiratory findings are not a finding that needs to be reported to the provider unless they indicate respiratory distress or infection. The normal respiratory rate for a newborn is 30 to 60 breaths per minute.
Choice C:
Serum glucose is a finding that needs to be reported to the provider, as it is higher than the normal range for a newborn. The normal serum glucose level for a newborn is usually just under 2 mmol/L (or 25 mg/dL) at birth, and it will rise to over 3 mmol/L (or 60 to 100 mg/dL) within two to three days. A serum glucose level of 130 mg/dL indicates hyperglycemia, which can have various causes and complications.
Choice D:
Hematocrit is a finding that needs to be reported to the provider, as it is lower than the normal range for a newborn. The normal hematocrit level for a newborn is 44% to 64%. A hematocrit level of 35% indicates anemia, which can have various causes and complications.
Choice E:
White blood cell count is not a finding that needs to be reported to the provider, as it is within the normal range for a newborn. The normal white blood cell count for a newborn is 9,000 to 30,000/mm³.
Choice F:
Hemoglobin is a finding that needs to be reported to the provider, as it is lower than the normal range for a newborn. The normal hemoglobin level for a newborn is 14 to 24 g/dL. A hemoglobin level of 9 g/dL indicates anemia, which can have various causes and complications.
Correct Answer is B
Explanation
Choice A reason:
Nevus flammeus is a port-wine stain, a type of birthmark that is present at birth and does not fade over time. It is caused by a malformation of capillaries in the skin and appears as a reddish-purple patch. It can occur anywhere on the body but is not associated with swelling or suture lines.
Choice B reason:
Cephalhematoma is a collection of blood under the periosteum of the skull bone, usually caused by trauma during delivery. It appears as a swollen area on the head that does not cross the suture line because it is limited by the boundaries of the bone. It usually resolves within a few weeks or months without treatment.
Choice C reason:
Molding is the temporary change in the shape of the newborn's head due to the pressure of the birth canal during delivery. It results in an elongated or cone-shaped head that may cross the suture line. It usually resolves within a few days as the skull bones return to their normal position.
Choice D reason:
Caput succedaneum is a localized swelling of the scalp, usually caused by pressure from the cervix or vacuum extraction during delivery. It appears as a soft, puffy area on the head that crosses the suture line because it is not limited by the bone. It usually resolves within a few days without treatment.
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