A nurse is teaching the parents of a newborn about the critical congenital heart disease screening.
Which of the following statements should the nurse include in the teaching?
The test will be performed when your newborn is between 6 and 12 hours of age.
It will take 1 to 2 weeks to obtain the results of your newborn's test.
The test compares the oxygen saturation in your newborn's upper and lower extremities.
To perform the test, I will collect a blood sample from your newborn's heel.
The Correct Answer is C
Choice A rationale
The critical congenital heart disease (CCHD) screening is typically performed when the newborn is between 24 and 48 hours of age, or just prior to discharge if that occurs earlier. Performing the test too early, such as between 6 and 12 hours, might yield false negative results due to the persistence of transitional circulation.
Choice B rationale
The results of the CCHD screening are typically available immediately, or within a few minutes, as it involves pulse oximetry readings. There is no waiting period of 1 to 2 weeks for the results, allowing for prompt identification and management of potential cardiac defects, preventing delays in care.
Choice C rationale
The CCHD screening specifically compares the oxygen saturation in the newborn's right hand (pre-ductal) and either foot (post-ductal). A significant difference between these two readings can indicate a shunt or obstruction within the heart or great vessels, suggesting a potential critical congenital heart defect.
Choice D rationale
Collecting a blood sample from the newborn's heel is the procedure for the newborn metabolic screening, which screens for various genetic and metabolic disorders, not the critical congenital heart disease screening. The CCHD screening is a non-invasive test performed using pulse oximetry.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Avoiding sterile vaginal examinations is not a primary action for uterine atony and large vaginal bleeding. While excessive or repeated vaginal examinations can potentially introduce infection or dislodge clots, the immediate priority for uterine atony is to address the lack of uterine tone to prevent further blood loss.
Choice B rationale
Obtaining a specimen for a Kleihauer-Betke test is used to quantify the amount of fetal red blood cells in the maternal circulation, typically after a significant feto-maternal hemorrhage or trauma. While potentially useful in specific situations, it is not an immediate, primary intervention for acute uterine atony and bleeding.
Choice C rationale
Performing a fundal massage is the most immediate and critical action for uterine atony. Uterine atony is the leading cause of postpartum hemorrhage, characterized by a boggy, relaxed uterus that cannot effectively constrict blood vessels at the placental site. Manual massage stimulates uterine contractions, promoting vasoconstriction and reducing blood loss.
Choice D rationale
Assessing for abdominal tenderness is an important assessment, but it is not the primary intervention for acute uterine atony with large vaginal bleeding. Abdominal tenderness could indicate other complications such as uterine rupture or hematoma, which require different immediate interventions after addressing the atony.
Correct Answer is D
Explanation
Choice A rationale
Urinary output of 20 mL/hr is indicative of oliguria, which is a significant adverse effect of magnesium sulfate therapy. Magnesium is renally excreted, and decreased urinary output can lead to magnesium toxicity. The desired urinary output for a client receiving magnesium sulfate should be at least 25 to 30 mL/hr to ensure adequate drug excretion.
Choice B rationale
Fetal heart rate pattern with minimal variability is a concerning finding and can indicate central nervous system depression in the fetus, potentially due to excessive magnesium levels. Normal fetal heart rate variability reflects a healthy autonomic nervous system. Magnesium sulfate's therapeutic effect is on the mother, not directly on fetal heart rate variability.
Choice C rationale
A change in fetal heart rate from 150/min to 166/min, while still within the normal range (110-160 bpm), does not directly indicate the desired therapeutic effect of magnesium sulfate for preeclampsia. This fluctuation could be due to various factors and is not a primary indicator of successful seizure prophylaxis or blood pressure control.
Choice D rationale
Magnesium sulfate is a central nervous system depressant that works by blocking neuromuscular transmission, thereby reducing hyperreflexia associated with preeclampsia. A decrease in deep tendon reflexes from 4+ (hyperactive) to 2+ (normal) indicates that the medication is achieving its desired therapeutic effect of central nervous system depression and reducing seizure risk.
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