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
Explanation
Choice A reason:
Transferring the newborn to the NICU is not the best action to take next, because it does not address the immediate problem of low blood sugar. The newborn may need to be transferred to the NICU later, depending on the cause and severity of the hypoglycemia, but the first priority is to raise the blood glucose level.
Choice B reason:
Calling the lab for a STAT blood glucose level is not the best action to take next, because it will delay the treatment of hypoglycemia. The glucometer reading is a reliable indicator of low blood sugar, and waiting for a lab confirmation will waste valuable time. The nurse should act on the glucometer reading and initiate treatment as soon as possible.
Choice C reason:
Initiating breastfeeding is the best action to take next, because it will provide the newborn with a source of glucose that can raise the blood sugar level quickly. Breastfeeding also has other benefits for the newborn, such as promoting bonding, providing antibodies, and reducing the risk of infection. Breastfeeding should be initiated within the first hour of life for all newborns, unless contraindicated.
Choice D reason:
Recognizing this as a normal reading and documenting it is not the best action to take next, because it is not a normal reading for a 2 hour old newborn. The normal range of blood glucose for a newborn is 40 to 150 mg/dL. A reading of 32 mg/dL indicates hypoglycemia, which can have serious consequences for the newborn's brain development and function. Hypoglycemia should be treated promptly and documented accordingly.
Correct Answer is A
Explanation
Choice A reason:
FAS is caused by alcohol, and NAS is caused by opioids. This is the correct answer because FAS stands for fetal alcohol syndrome, which is a group of physical and mental defects that can occur in a baby when a woman drinks alcohol during pregnancy. NAS stands for neonatal abstinence syndrome, which is a group of problems that can happen when a baby is exposed to opioid drugs for a length of time while in their mother's womb.
Choice B reason:
FAS and NAS are both incurable. This is incorrect because FAS and NAS have different outcomes. FAS is incurable because the effects of alcohol on the developing brain and body are permanent. NAS, however, can be treated with medication and supportive care to help the baby cope with withdrawal symptoms and prevent complications.
Choice C reason:
FAS and NAS are both curable. This is incorrect because FAS is not curable, as explained above. NAS can be treated, but not cured, because some babies may have long-term problems such as developmental delays, behavioral issues, or learning difficulties.
Choice D reason:
FAS is caused by analgesics and NAS is caused by NSAIDs. This is incorrect because FAS is caused by alcohol, not analgesics, which are painkillers. NAS is caused by opioids, not NSAIDs, which are anti-inflammatory drugs. Analgesics and NSAIDs do not cause the same type of damage to the fetus or the newborn as alcohol and opioids do.
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.