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

Answer and Explanation

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.

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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.

A. Preterm birth B. Cesarean birth C. Precipitous delivery D. Frequent vaginal exams E. Mother has GBS infection

Correct Answer is ["A","C","D","E"]

Explanation

Choice A reason:

Preterm birth is a major risk factor for neonatal sepsis, especially early-onset sepsis. Preterm babies have immature immune systems and lack antibodies to protect them against certain bacteria.

Choice B reason:

Cesarean birth is not a risk factor for neonatal sepsis by itself, unless it is associated with other factors such as prolonged rupture of membranes, maternal infection or chorioamnionitis.

Choice C reason:

Precipitous delivery is a risk factor for neonatal sepsis, especially early-onset sepsis. Precipitous delivery can cause fetal distress, hypoxia, acidosis and increased susceptibility to infection.

Choice D reason:

Frequent vaginal exams are a risk factor for neonatal sepsis, especially early-onset sepsis. Frequent vaginal exams can introduce bacteria into the amniotic fluid and increase the risk of ascending infection.

Choice E reason:

Mother has GBS infection is a risk factor for neonatal sepsis, especially early-onset sepsis. GBS (group B streptococcus) is the most common cause of early-onset neonatal sepsis and can be transmitted from the mother to the baby during labor and delivery.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is updating the plan of care for a newborn who is undergoing phototherapy. Which of the following actions should the nurse include in the plan?

Correct Answer is D

Explanation

What are the risk factors for neonatal sepsis? Select all that apply. (Select All that Apply.).

Correct Answer is ["A","C","D","E"]

Explanation

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