A nurse on the labor and delivery unit is assisting in the care of a newborn at 1 hour old.
Click to highlight the findings that require follow-up. To deselect a finding, click on the finding again.
A. A full-term newborn was delivered vaginally.
B. APGAR was 7 at 1 min and 9 at 5 min.
C. Newborn is 48.26 cm (19 in) and 4,224 g (9 lb 5 oz).
D. Acrocyanosis present.
E. Heart rate 150/min, temperature 36.5°C (97.7°F) rectally, and respiratory rate 45/min.
F. Newborn was breastfed immediately after birth but had difficulty latching.
G. During nurse data collection, the newborn is jittery with abnormal crying.
H. Temperature 36.3°C (97.3°F) with mild hypotonia.
A full-term newborn was delivered vaginally.
APGAR was 7 at 1 min and 9 at 5 min.
Newborn is 48.26 cm (19 in) and 4,224 g (9 lb 5 oz).
Acrocyanosis present.
Heart rate 150/min, temperature 36.5°C (97.7°F) rectally, and respiratory rate 45/min.
Newborn was breastfed immediately after birth but had difficulty latching.
During nurse data collection, the newborn is jittery with abnormal crying.
Temperature 36.3°C (97.3°F) with mild hypotonia.
The Correct Answer is ["C","F","G","H"]
Choice A rationale: A full-term vaginal delivery is a normal and expected finding. Term gestation ranges from 37 to 42 weeks, and vaginal delivery is a common mode of birth associated with fewer complications than cesarean delivery. This finding does not indicate any abnormality or need for follow-up, as it reflects a standard, uncomplicated birth process.
Choice B rationale: APGAR scores of 7 at 1 minute and 9 at 5 minutes are within the normal range. A score of 7 to 10 is considered reassuring, indicating that the newborn is adapting well to extrauterine life. The improvement from 7 to 9 suggests effective transition and no ongoing distress, so no follow-up is required for this finding.
Choice C rationale: A weight of 4,224 g (9 lb 5 oz) classifies the newborn as macrosomic, which is defined as a birth weight over 4,000 g. Macrosomia increases the risk for neonatal hypoglycemia due to hyperinsulinemia from in utero exposure to maternal glucose. This condition requires close monitoring of blood glucose levels and feeding effectiveness to prevent complications like seizures or neurologic injury.
Choice D rationale: Acrocyanosis, or bluish discoloration of the hands and feet, is a common and benign finding in newborns during the first 24 to 48 hours of life. It results from immature peripheral circulation and does not indicate central cyanosis or hypoxia. Therefore, it is not a finding that requires follow-up unless it persists or is accompanied by other signs of distress.
Choice E rationale: A heart rate of 150/min, respiratory rate of 45/min, and rectal temperature of 36.5°C (97.7°F) are all within normal neonatal ranges. Normal heart rate is 120–160/min, respiratory rate is 30–60/min, and rectal temperature is 36.5–37.5°C. These values indicate stable vital signs and do not necessitate follow-up.
Choice F rationale: Difficulty latching during initial breastfeeding attempts may indicate poor feeding effectiveness, which is a concern in the context of neonatal hypoglycemia. Inadequate intake can exacerbate low glucose levels and delay stabilization. This finding requires follow-up to ensure the infant is feeding effectively and maintaining adequate glucose levels.
Choice G rationale: Jitteriness and abnormal crying are neurologic signs that may indicate hypoglycemia, hypocalcemia, or neurologic dysfunction. In this case, the newborn’s glucose was 35 mg/dL, below the normal threshold of 40–45 mg/dL. These symptoms warrant follow-up to monitor for recurrence and ensure resolution with feeding and glucose stabilization.
Choice H rationale: A temperature of 36.3°C (97.3°F) is slightly below the normal range of 36.5–37.5°C, indicating mild hypothermia. Mild hypotonia in conjunction with hypoglycemia and low temperature suggests systemic instability. These findings require follow-up to ensure thermoregulation and neurologic tone normalize with appropriate interventions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is []
Explanation
Rationale for correct condition Endometritis is a postpartum uterine infection, often following cesarean birth and prolonged rupture of membranes. It presents with a boggy, tender uterus, foul-smelling lochia, fever or chills, and malaise. This client’s symptoms—uterine tenderness, foul lochia, and systemic signs—are classic for endometritis. Bottle-feeding increases risk due to lack of uterine oxytocin stimulation. Early recognition is critical to prevent sepsis.
Rationale for correct actions Oxytocin promotes uterine contractions, aiding involution and reducing bacterial proliferation in retained lochia. A firm uterus also minimizes bleeding. Broad-spectrum antibiotics target polymicrobial pathogens common in endometritis, including Escherichia coli and anaerobes. Prompt antibiotic therapy reduces systemic spread and improves recovery.
Rationale for correct parameters Lochia characteristics reflect uterine healing; foul odor and increased volume suggest ongoing infection. Monitoring changes helps evaluate treatment response. Temperature is a key systemic marker of infection; decreasing fever indicates therapeutic effectiveness. Persistent fever may signal treatment failure or complications.
Rationale for incorrect conditions Urinary tract infection typically presents with dysuria, urgency, and suprapubic pain—not uterine tenderness or foul lochia. Deep vein thrombosis involves unilateral leg pain, swelling, and warmth, which are absent here. Engorgement causes breast discomfort, not systemic symptoms or uterine findings.
Rationale for incorrect actions Increased fluid intake supports general health but does not directly treat endometritis. Anticoagulants are used for thrombosis, not uterine infection. Ice packs relieve breast engorgement but are unrelated to uterine infection management.
Rationale for incorrect parameters Leg circumference is relevant for DVT, not uterine infection. Nipple integrity is important for breastfeeding issues, not applicable here. Bladder distention is not contributing to uterine tenderness or infection in this case.
Take home points
- Endometritis is a common postpartum infection, especially after cesarean birth and prolonged rupture of membranes.
- Key signs include uterine tenderness, foul-smelling lochia, and systemic symptoms like fever or chills.
- Management includes uterotonic agents and broad-spectrum antibiotics.
- Differentiate from UTI, DVT, and breast engorgement based on localized versus systemic findings.
Correct Answer is A
Explanation
Choice A rationale
Late-preterm newborns, born between 34 weeks 0 days and 36 weeks 6 days of gestation, have immature physiological systems. Their underdeveloped thermoregulatory centers and reduced subcutaneous fat make them highly susceptible to heat loss, leading to thermal instability and hypothermia risk.
Choice B rationale
Leathery skin is characteristic of a post-term newborn, typically born at 42 weeks of gestation or beyond. This is due to prolonged exposure to amniotic fluid, resulting in desiccation, cracking, and peeling, a sign of post-maturity, not late-preterm status.
Choice C rationale
Late-preterm newborns are more prone to hypoglycemia, not hyperglycemia. Their immature liver glycogen stores, increased metabolic demands, and inefficient gluconeogenesis make them vulnerable to low blood glucose levels, particularly during periods of stress or inadequate feeding.
Choice D rationale
An alert, wide-eyed appearance is more characteristic of a full-term or post-term newborn. Late-preterm newborns often exhibit less mature neurological development, appearing sleepier, less alert, and demonstrating weaker sucking reflexes due to their developmental immaturity.
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