A nurse is providing care for a patient who is in labor.
After reviewing the patient’s medical history, vital signs, nurse’s notes, and diagnostic results, which of the following complications should the nurse identify that the patient is at risk of developing?

Chorioamnionitis

Preeclampsia

Gestational diabetes

Preterm labor

Answer and Explanation

The Correct Answer is A

Choice A rationale

Chorioamnionitis. Based on the information provided, the patient is at risk of developing chorioamnionitis, which is an infection of the membranes surrounding the fetus.

Choice B rationale

Preeclampsia. There is no information provided that would indicate the patient is at risk of developing preeclampsia.

Choice C rationale

Gestational diabetes. There is no information provided that would indicate the patient is at risk of developing gestational diabetes.

Choice D rationale

Preterm labor. There is no information provided that would indicate the patient is at risk of developing preterm labor.

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Correct Answer is D

Explanation

Choice A rationale: An awake, alert, and crying newborn is a common observation and does not specifically indicate Neonatal Abstinence Syndrome (NAS). Newborns have varying sleep-wake cycles, and it’s normal for them to have periods of being awake and alert. Crying is also a normal behavior for newborns as it’s their primary means of communication. It could indicate a variety of needs such as hunger, the need for a diaper change, or just the need for comfort and contact. Therefore, while an excessively crying baby could potentially be a sign of discomfort or distress, it is
not specifically indicative of NAS.
Choice B rationale: The presence of acrocyanosis, which is the bluish color of the hands and feet, is a normal finding in the first 24 to 48 hours of life due to immature circulation. It’s not specifically associated with NAS. NAS is a group of problems that occur in a newborn who was exposed to addictive opiate drugs while in the mother’s womb. Acrocyanosis is generally not a symptom of NAS.
Choice C rationale: A respiratory rate of 70/min is higher than the normal range (30-60/min) for a newborn and could indicate respiratory distress. However, it’s not specifically indicative of NAS. There are many potential causes of tachypnea (increased respiratory rate) in a newborn, including transient tachypnea of the newborn (TTN), respiratory distress syndrome (RDS), pneumonia, meconium aspiration syndrome (MAS), and more. While infants with NAS mayexperience symptoms such as stuffy nose, sneezing, and rapid breathing, a high respiratory rate alone is not specifically indicative of NAS.
Choice D rationale: Jitteriness in the hands of a newborn can be a sign of Neonatal Abstinence Syndrome (NAS). NAS is a drug withdrawal syndrome in newborns that occurs primarily among opioid-exposed infants shortly after birth, often manifested by central nervous system irritability, autonomic overreactivity, and gastrointestinal tract dysfunction. Jitteriness or tremors, especially when disturbed, along with other signs such as high-pitched crying, poor feeding, and
loose stools, are more indicative of NAS.

A. Physiologic jaundice. B. Maternal/newborn blood group incompatibility. C. Maternal cocaine abuse. D. Absence of vitamin K. .

Correct Answer is A

Explanation

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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A nurse is providing care for a patient who is in labor. After reviewing the patient’s medical history, vital signs, nurse’s notes, and diagnostic results, which of the following complications should the nurse identify that the patient is at risk of developing?

Choice B rationale

Choice C rationale

Choice D rationale

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Correct Answer is D

Explanation

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?

Correct Answer is A

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

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A nurse is providing care for a patient who is in labor.
After reviewing the patient’s medical history, vital signs, nurse’s notes, and diagnostic results, which of the following complications should the nurse identify that the patient is at risk of developing?