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A nurse is caring for a newborn

Exhibits

Which findings are risk factors for the newborn to develop a complication? Select all that apply

A.

Maternal Rh factor

B.

Gestational age

C.

Apgar scores

D.

Weight

E.

Type of birth

F.

Length

Answer and Explanation

Correct Answer : B,E

A. Maternal Rh factor – The mother is O positive. Rh incompatibility is not a concern here because both mother and newborn are likely Rh positive, and no information suggests Rh incompatibility.
B. Gestational age – The newborn was born at 36 weeks and 4 days, which is considered late preterm and places the infant at increased risk for complications such as respiratory distress, jaundice, hypoglycemia, and feeding difficulties.
C. Apgar scores – Scores of 7 at 1 minute and 8 at 5 minutes are within the normal range and not indicative of distress or a complication risk.
D. Weight – A birth weight of 3,062 g (6 lb 12 oz) is appropriate for gestational age and not a risk factor.
E. Type of birth – Operative vaginal birth using a vacuum extractor increases the risk for complications like cephalohematoma, which is noted in the assessment (firm, edematous scalp area with ecchymosis not crossing suture lines). This can contribute to jaundice.
F. Length – A length of 48 cm (19 in) is appropriate for gestational age and not a risk factor.


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Related Questions

Correct Answer is C

Explanation

A. HSV-2 can cause neonatal herpes, which may result in serious complications or fetal demise if transmitted at delivery.
B. Tight-fitting undergarments can increase moisture and irritation; clients should wear loose cotton underwear to promote healing.
C. The risk of neonatal transmission is highest when active lesions or viral shedding are present at the time of vaginal delivery.
D. Antiviral medications (e.g., acyclovir) suppress viral replication and reduce outbreaks and shedding but do not eradicate the virus.

Correct Answer is ["A","B"]

Explanation

  • Oral temperature 38.3°C (101°F)
    Elevated temperature indicates maternal fever, which could suggest infection such as chorioamnionitis, especially concerning with ruptured membranes.
  • HGB 10 g/dL (normal > 11 g/dL)
    Low hemoglobin indicates anemia, which could compromise oxygen delivery to the fetus and affect maternal health during labor.

Explanation for non-highlighted findings:

  • Heart rate 98/min: Slightly elevated but within normal range for labor.
  • Blood pressure 112/59 mm Hg: Normal blood pressure for pregnancy.
  • Uterine contractions every 3 mins moderate to palpation: Normal pattern for active labor.

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