A nurse is caring for four newborns.
Which of the following newborns should the nurse assess first?
A newborn who has subconjunctival hemorrhage of the left eye.
A newborn who has rust-stained urine.
A newborn who has nasal flaring.
A newborn who has overlapping suture lines.
The Correct Answer is C
Choice A rationale
Subconjunctival hemorrhage is a common, generally benign finding in newborns, often resulting from increased intraocular pressure during the birthing process, causing rupture of superficial capillaries in the sclera. It presents as a bright red patch under the conjunctiva and usually resolves spontaneously within a few weeks without intervention, thus it does not warrant immediate, priority assessment.
Choice B rationale
Rust-stained urine, or pink-tinged urine, in a newborn is typically due to the presence of uric acid crystals (urates) in the urine, a normal finding related to concentrated urine and the immaturity of the newborn kidney's ability to concentrate urine fully. This is a common, non-pathological observation in the first few days of life, indicating mild dehydration, but it is not an acute, high-priority concern.
Choice C rationale
Nasal flaring is a significant sign of respiratory distress in a newborn, indicating the infant is attempting to increase the diameter of the nasal passages to decrease airway resistance and enhance the intake of oxygen. This compensatory mechanism suggests compromised gas exchange and potential hypoxemia, requiring immediate assessment and intervention to prevent further respiratory compromise.
Choice D rationale
Overlapping suture lines, also known as molding, occurs when the cranial bones shift and overlap during passage through the narrow birth canal. This is a normal, expected finding, especially after a vaginal delivery, and the shape of the head typically returns to normal within a few days to a week, posing no immediate threat to the newborn.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"A,B,C"},"B":{"answers":"B,C"},"C":{"answers":"B"},"D":{"answers":"C"},"E":{"answers":"B,C"}}
Explanation
Vaginal bleeding
Bleeding occurs in placenta previa due to partial or total implantation of the placenta over the cervical os, leading to painless bright red bleeding from disrupted placental vessels. It also occurs in preterm labor when cervical effacement and dilation disrupt small cervical vessels, producing light bleeding or spotting. In abruptio placenta, bleeding is dark red and may be concealed or apparent, resulting from premature placental detachment and rupture of maternal vessels in the decidua basalis.
Uterine contractions
Regular uterine contractions every 2 to 3 minutes with cervical change are diagnostic of preterm labor, resulting from premature activation of uterine oxytocin receptors and prostaglandin release before 37 weeks. In abruptio placenta, contractions are often strong and sustained (hypertonic uterus) due to myometrial irritability from bleeding into the decidual layer. Placenta previa, however, typically presents with painless bleeding and a soft, relaxed uterus without contractions because the uterine muscle tone remains unaffected.
Cervical dilation
Cervical dilation indicates preterm labor, as biochemical changes in the cervix from increased prostaglandin and relaxin activity cause collagen breakdown and effacement before term. This process reflects uterine activation sequence initiation leading to potential preterm birth. In placenta previa, the cervix may remain closed despite bleeding because bleeding originates from placental implantation, not cervical change. Abruptio placenta rarely involves dilation unless labor progresses secondarily after placental separation, thus cervical dilation is not a key feature.
Abdominal tenderness
Abdominal tenderness is characteristic of abruptio placenta, caused by bleeding between the uterine wall and placenta leading to myometrial irritability, uterine rigidity, and ischemic pain. The trapped blood increases intrauterine pressure, stimulating pain receptors in the myometrium and stretching the uterine serosa. Placenta previa presents with a soft, nontender abdomen because bleeding is external and not associated with uterine muscle involvement. Preterm labor generally causes back discomfort or cramping, not localized abdominal tenderness.
Client report of low back pain
Low back pain is prominent in preterm labor, resulting from referred pain due to rhythmic uterine contractions transmitted through the lumbosacral plexus and pelvic nerves. It reflects early cervical change and uterine irritability. In abruptio placenta, the back pain may occur secondary to uteroplacental separation and posterior placental bleeding irritating the parietal peritoneum. Placenta previa typically lacks pain or back discomfort since bleeding occurs without uterine or peritoneal irritation.
Correct Answer is ["A","C","E"]
Explanation
Choice A rationale
Oxytocin use for labor induction or augmentation is a significant risk factor for uterine atony, the most common cause of postpartum hemorrhage (PPH). Prolonged or high-dose exposure can lead to receptor downregulation or overstimulation, resulting in a fatigued or poorly contracting uterus, which fails to clamp down on the blood vessels at the placental site after delivery.
Choice B rationale
A history of Human Papillomavirus (HPV), a sexually transmitted infection, is not recognized as an independent risk factor for increasing the likelihood of postpartum hemorrhage. The physiological mechanisms leading to PPH are primarily related to uterine function, trauma, or coagulation disorders, which HPV infection does not directly influence.
Choice C rationale
A history of uterine atony in a previous pregnancy significantly increases the risk for recurrence in subsequent deliveries because it suggests an underlying predisposition for the myometrium to fail its contractile function. Uterine atony prevents the spiral arteries from being compressed, leading to excessive blood loss, which defines postpartum hemorrhage.
Choice D rationale
The average newborn weight in Western populations is approximately 3.4 kg (7.5 lb), with a normal range generally considered between 2.5 kg and 4.0 kg. A newborn weight of 2.948 kg (6 lb 8 oz) is within the normal range and does not constitute a risk factor for PPH, unlike macrosomia (birth weight > 4000 g or 8 lb 13 oz) which overdistends the uterus.
Choice E rationale
Vacuum-assisted delivery, a form of operative vaginal delivery, increases the risk of PPH primarily due to associated genital tract trauma (e.g., cervical, vaginal, or perineal lacerations) and potentially compounding the risk of uterine atony from prolonged labor or necessary manual maneuvers. Trauma contributes to bleeding that is non-uterine in origin.
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