A nurse is caring for a newborn in the labor and delivery unit.
A nurse on the labor and delivery unit is assisting in the care of a newborn at 1 hr old.
Click to highlight the findings that require follow-up. To deselect a finding, click on the finding again.
APGAR score of 7 at 1 minute and 9 at 5 minutes
Birth weight of 4,224 g (9 lb 5 oz)
Acrocyanosis present
Difficulty latching during initial breastfeeding
Jitteriness with abnormal crying
Temperature 36.3° C (97.3° F) with mild hypotonia
Correct Answer : B,D,E,F
Choice A rationale: An Apgar score of 7 at 1 minute and 9 at 5 minutes reflects appropriate neonatal transition. The Apgar scale assesses heart rate, respiratory effort, muscle tone, reflex irritability, and color. A score of 7–10 is considered normal. Improvement from 7 to 9 indicates effective adaptation to extrauterine life. No follow-up is required unless scores remain below 7 or decline, which could suggest perinatal compromise or need for resuscitation.
Choice B rationale: A birth weight of 4,224 g (9 lb 5 oz) classifies the newborn as large for gestational age (LGA), which increases the risk for neonatal hypoglycemia. LGA infants often experience hyperinsulinemia due to maternal diabetes or excessive glucose exposure in utero. After birth, insulin levels remain high while glucose supply drops, leading to hypoglycemia. This metabolic imbalance requires close monitoring of glucose levels and feeding adequacy to prevent neurologic sequelae.
Choice C rationale: Acrocyanosis is a benign finding in the first 24–48 hours of life due to immature peripheral circulation. It presents as bluish discoloration of the hands and feet while central perfusion remains intact. It does not indicate hypoxemia or cardiovascular compromise. The condition resolves spontaneously as peripheral vasomotor tone matures. No follow-up is needed unless central cyanosis or respiratory distress develops, which would suggest a more serious pathology.
Choice D rationale: Difficulty latching during initial breastfeeding can lead to inadequate caloric intake and increase the risk of hypoglycemia, especially in LGA infants. Effective latching is essential for milk transfer and glucose stabilization. Poor latch may result from anatomical issues, maternal technique, or infant fatigue. Early intervention with lactation support is critical to ensure feeding success and prevent metabolic instability. This finding warrants follow-up to optimize nutrition and glucose regulation.
Choice E rationale: Jitteriness with abnormal crying is a clinical sign of neonatal hypoglycemia. Hypoglycemia affects neuronal excitability, leading to tremors, irritability, and altered cry patterns. Blood glucose levels below 40–45 mg/dL impair cerebral function and may cause seizures if untreated. Jitteriness must be differentiated from normal newborn tremors, and glucose levels should be promptly assessed. This symptom requires immediate follow-up to prevent neurologic injury and ensure metabolic stability.
Choice F rationale: A temperature of 36.3° C (97.3° F) with mild hypotonia suggests hypothermia and possible hypoglycemia. Neonates have limited thermoregulatory capacity and rely on brown fat metabolism, which consumes glucose. Hypothermia increases glucose utilization, exacerbating hypoglycemia risk. Mild hypotonia reflects reduced neuromuscular tone, a sign of central nervous system depression. These findings require follow-up to stabilize temperature and glucose levels, preventing further metabolic compromise.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D","E"]
Explanation
Choice A rationale: A fundal height of 27 cm at 21 weeks gestation exceeds the expected range. Normally, fundal height in centimeters should approximate gestational age between 20 and 36 weeks, with a ±2 cm margin. At 21 weeks, a fundal height of 19–23 cm is acceptable. A measurement of 27 cm suggests possible fetal macrosomia, polyhydramnios, or gestational diabetes, especially in a client with elevated glucose levels and obesity. This warrants follow-up.
Choice B rationale: Fetal heart tones of 145/min fall within the normal range of 110 to 160 beats per minute. This rate reflects appropriate fetal autonomic regulation and oxygenation. Variability in fetal heart rate is expected and indicates a healthy intrauterine environment. No arrhythmia or bradycardia is present. Therefore, this finding does not require follow-up and supports normal fetal well-being at this gestational age.
Choice C rationale: A 1-hour glucose level of 220 mg/dL following a 100-g oral glucose load exceeds the threshold of less than 180 mg/dL. This result indicates impaired glucose tolerance and supports the diagnosis of gestational diabetes mellitus (GDM). GDM increases risks for fetal macrosomia, shoulder dystocia, and neonatal hypoglycemia. Follow-up is required to initiate dietary management, glucose monitoring, and possibly pharmacologic therapy to prevent maternal and fetal complications.
Choice D rationale: A 3-hour glucose level of 142 mg/dL exceeds the normal range of 70 to 115 mg/dL. This result confirms abnormal glucose metabolism and supports the diagnosis of gestational diabetes. The 3-hour value reflects delayed glucose clearance and persistent hyperglycemia. This finding, in conjunction with other elevated values, meets criteria for GDM and necessitates follow-up for glycemic control, nutritional counseling, and fetal surveillance to mitigate adverse outcomes.
Choice E rationale: A blood pressure of 140/88 mm Hg meets the threshold for gestational hypertension, defined as systolic ≥140 mm Hg or diastolic ≥90 mm Hg after 20 weeks gestation. Although the client denies symptoms of preeclampsia, such as headache or visual changes, her history of chronic hypertension and obesity increases risk. Continued monitoring and possible adjustment of antihypertensive therapy are warranted to prevent progression to preeclampsia or eclampsia.
Choice F rationale: Denial of headaches, visual disturbances, and epigastric pain suggests absence of preeclampsia symptoms. These symptoms reflect end-organ involvement and vasospasm in severe hypertensive disorders. Their absence supports stable maternal status. However, clinical vigilance remains important due to the client’s elevated blood pressure and risk factors. At this time, no follow-up is required solely based on symptom denial.
Correct Answer is A
Explanation
Choice A rationale
Nalbuphine hydrochloride is a synthetic opioid agonist-antagonist analgesic often used for pain relief during labor. Its agonist effects on kappa (κ) opioid receptors in the central nervous system lead to analgesia and common side effects, including central nervous system depression. Sedation is a frequent manifestation of this effect, caused by the drug's action on brain centers controlling arousal.
Choice B rationale
Nalbuphine primarily acts as an opioid, and its μ-receptor antagonist activity counteracts some opioid effects, but typical opioid-related gastrointestinal effects include decreased peristalsis, often leading to constipation. Diarrhea is not a common or expected adverse effect of nalbuphine; instead, it tends to slow gut motility due to its opioid effects on the enteric nervous system.
Choice C rationale
Opioid use, including nalbuphine, can sometimes lead to the adverse effect of urinary retention, due to increased detrusor muscle tone and internal sphincter spasm, which is a suppression of the micturition reflex. Diuresis, which is an increased or excessive production of urine, is not a recognized adverse effect of this medication.
Choice D rationale
Opioids, such as nalbuphine, typically interact with the thermoregulatory centers in the hypothalamus, often resulting in hypothermia due to vasodilation and decreased metabolic rate, not fever. Fever (pyrexia) is not a common or characteristic adverse effect associated with the administration of nalbuphine hydrochloride during labor.
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