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 B
Explanation
Choice A rationale
The proper sequence for suctioning a newborn is the mouth first, then the nose, to prevent the newborn from aspirating secretions. Suctioning the nose first may cause the newborn to gasp, drawing pharyngeal secretions into the trachea and lungs, potentially leading to aspiration pneumonia or respiratory distress.
Choice B rationale
Depressing the bulb prior to insertion into the mouth or nose creates a negative pressure inside the bulb. Releasing the pressure after insertion will then effectively draw secretions into the bulb, achieving optimal suction. Inserting a non-depressed bulb will be ineffective for removing secretions.
Choice C rationale
The bulb syringe does not require lubrication with sterile water before use; it is intended for immediate use as a mechanical suction device. Lubrication could potentially introduce excess fluid into the newborn's airway or dilute secretions, which does not enhance the device's primary function of removing mucus.
Choice D rationale
The bulb should be placed gently into the sides of the newborn's mouth, rather than the center, to avoid stimulating the gag reflex. Placing it at the sides directs suction toward the cheeks and gums, facilitating the removal of secretions from the oral cavity without causing discomfort or vomiting.
Correct Answer is A
Explanation
Choice A rationale
Applying witch hazel compresses (such as Tucks pads) is an effective and preferred action for postpartum perineal discomfort, including episiotomy pain. Witch hazel contains tannins and volatile oils that provide an astringent and anti-inflammatory effect. This action helps to reduce swelling, soothe the tissues, and offer immediate, localized pain relief at the episiotomy site.
Choice B rationale
Administering aspirin (acetylsalicylic acid) for postpartum discomfort is generally contraindicated. Aspirin is a non-steroidal anti-inflammatory drug (NSAID) with antiplatelet effects, which could increase the risk of bleeding postpartum, especially from the placental insertion site or the episiotomy wound. Preferred analgesics are typically acetaminophen or ibuprofen, which have less impact on coagulation.
Choice C rationale
Having the client use a warm pack is not the initial treatment for episiotomy pain within the first 24 hours. Heat promotes vasodilation, which can increase edema and pain in the acutely inflamed and traumatized tissues. Cold therapy (e.g., ice packs) is the standard initial treatment because it causes vasoconstriction, which minimizes swelling and provides a local anesthetic effect.
Choice D rationale
Instructing the client to sit on a soft pillow might seem helpful, but it can sometimes be detrimental. Sitting on a soft, ring-shaped, or inflated pillow can cause the client to press outward on the soft tissues of the perineum, potentially increasing pressure and discomfort on the episiotomy incision. Sitting on a firm surface with the buttocks shifted can be more comfortable for some.
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