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 B

Explanation

Choice A reason:

This is incorrect because formula-fed newborns typically have one or more stools per day, not every 3 days. Stooling less frequently than once a day may indicate constipation.

Choice B reason:

This is correct because breastfed newborns usually have two to three stools per day, which are soft and yellow. Breastfed babies may also have stools less frequently, even once every 10-14 days, as long as the stool is soft.

Choice C reason:

This is incorrect because newborns should be fed formula on demand, not on a strict schedule. The average feeding interval for formula-fed newborns is about 3 to 4 hours.

Choice D reason:

This is incorrect because newborns should be breastfed eight to 12 times per day, not five to seven times. Breastfeeding more frequently helps to establish milk supply and prevent engorgement. - Stanford Medicine.

A. Sleepiness B. Constipation C. Irritability D. Absent or startle reflex

Correct Answer is C

Explanation

Choice A reason:

Sleepiness is not a symptom of withdrawal in newborns. Sleepiness may be caused by other factors such as hypoglycemia, hypothermia, or infection.

Choice B reason:

Constipation is not a symptom of withdrawal in newborns. Constipation may be caused by dehydration, formula intolerance, or lack of bowel stimulation.

Choice C reason:

Irritability is a symptom of withdrawal in newborns. Irritability may manifest as excessive crying, jitteriness, tremors, or increased muscle tone. Irritability is caused by the overstimulation of the central nervous system due to the absence of the drug that the newborn was exposed to in utero.

Choice D reason:

Absent or startle reflex is not a symptom of withdrawal in newborns. Absent or startle reflex may indicate neurological damage, hypoxia, or brachial plexus injury. The startle reflex, also known as the Moro reflex, is a normal response to sudden stimuli in newborns.

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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

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Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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