A nurse is admitting an 8-hour-old, term newborn following a cesarean birth. The nurse observes that the newborn’s skin is yellow.
This finding indicates the newborn is experiencing a complication related to which of the following?
Physiologic jaundice.
Maternal/newborn blood group incompatibility.
Maternal cocaine abuse.
Absence of vitamin K. .
The Correct Answer is A
Choice A rationale
Physiologic jaundice is a common condition in newborns, usually appearing between the second and fourth day of life. It is caused by an increase in bilirubin, a substance produced by the breakdown of red blood cells.
Choice B rationale
Maternal/newborn blood group incompatibility can cause jaundice, but it typically appears within the first 24 hours of life.
Choice C rationale
Maternal cocaine abuse can lead to various complications in the newborn, but it does not directly cause jaundice.
Choice D rationale
Absence of vitamin K does not cause jaundice. Vitamin K is given to newborns to prevent bleeding disorders.
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Related Questions
Correct Answer is ["B","C","D"]
Explanation
Choice A rationale
Resting in a recliner until the incision is healed is not recommended following a cesarean birth. It’s important for the client to gradually increase their activities and mobility to promote healing and prevent complications such as blood clots.
Choice B rationale
It’s crucial for the client to monitor their incision for signs of infection, such as increased redness, swelling, pain, or discharge. Therefore, calling the provider if there is discharge from the incision indicates understanding of the discharge instructions.
Choice C rationale
Resuming prenatal vitamins is often recommended after a cesarean birth to aid in recovery and support breastfeeding if the client chooses to breastfeed. Prenatal vitamins contain essential nutrients that can help the client heal and recover after surgery.
Choice D rationale
Unrelieved abdominal pain is not a normal part of recovery and could indicate a complication such as an infection or a problem with the incision. Therefore, the client should understand that they should not have unrelieved pain in their abdomen and should contact their provider if they do.
Correct Answer is D
Explanation
Choice A rationale
While seeing a counselor could be beneficial for some women experiencing doubts and second thoughts about their pregnancy, suggesting this as an initial response may make the client feel that her feelings are abnormal or require professional help.
Choice B rationale
Asking if the client has spoken to her mother about these feelings assumes that the client has a good relationship with her mother or that her mother is available for support, which may not be the case.
Choice C rationale
Telling the client not to worry and that she will be fine once the baby is born may minimize her feelings and does not acknowledge her current emotional state.
Choice D rationale
Ambivalent feelings are quite common for women early in pregnancy. This response validates the client’s feelings and reassures her that what she is experiencing is normal.
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