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 A
Explanation
Choice A reason:
Drying the newborn's skin thoroughly is the nurse's priority after assuring a patent airway because it reduces evaporative heat loss by the newborn and prevents cold stress. Cold stress can lead to hypoxia, hypoglycemia, acidosis, and increased bilirubin levels. Drying the newborn also stimulates breathing and crying, which are signs of a healthy newborn.
Choice B reason:
Administering phytonadione IM is not the nurse's priority because it is not an immediate life-saving intervention. Phytonadione is given to prevent hemorrhagic disease of the newborn, which is caused by vitamin K deficiency. However, this condition usually occurs after the first day of life, so administering phytonadione can be delayed until after the initial assessment and stabilization of the newborn.
Choice C reason:
Documenting the Apgar score is not the nurse's priority because it is not an action that directly affects the newborn's well-being. The Apgar score is a tool to assess the newborn's condition at 1 and 5 minutes after birth based on five criteria: heart rate, respiratory effort, muscle tone, reflex irritability, and color. The Apgar score can help guide the nurse's interventions, but it is not more important than providing care to the newborn.
Choice D reason:
Applying identification bands is not the nurse's priority because it is not an urgent or essential action. Identification bands are used to ensure the safety and security of the newborn and prevent errors or mix-ups. However, applying identification bands can be done after the newborn is dried, warmed, and assessed for any problems.
Correct Answer is ["C","E"]
Explanation
Choice A reason:
A prior vaginal delivery is not a contraindication for VBAC. In fact, it is a positive predictor of success for VBAC, as it indicates that the woman has a proven pelvis and can tolerate labor.
Choice B reason:
The gestation of 42 weeks is not a contraindication for VBAC. However, it is associated with an increased risk of stillbirth while awaiting spontaneous labor, which should be balanced against the risks of induction of labor or elective repeat cesarean.
Choice C reason:
Maternal obesity is a relative contraindication for VBAC. It is associated with a lower success rate of VBAC, a higher risk of uterine rupture, and a higher risk of maternal and neonatal complications. The decision to attempt VBAC in obese women should be made on a case-by-case basis by a senior obstetrician.
Choice D reason:
One prior cesarean delivery is not a contraindication for VBAC. Most women who have had one prior lower segment cesarean delivery are eligible for VBAC, as the risk of uterine rupture is low (0.5%) and the success rate is high (72-75%).
Choice E reason:
A macrosomic fetus is a relative contraindication for VBAC. It is associated with a lower success rate of VBAC, a higher risk of uterine rupture, and a higher risk of shoulder dystocia and birth trauma. The decision to attempt VBAC in women with suspected macrosomia should be made on a case-by-case basis by a senior obstetrician.
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