A nursery nurse is attending the birth of a post-term infant
Fill in each blank in the following sentence.
Upon review of the medical record, the nurse should determine the infant newborn is at risk for developing
The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C"}
Rationale for correct choices:
- Macrosomia: Post-term infants (≥42 weeks gestation) have prolonged exposure to intrauterine nutrients, increasing the risk of excessive fetal growth. Macrosomia is common and can lead to complications such as shoulder dystocia or birth trauma.
- Meconium aspiration syndrome: As gestation progresses beyond term, placental function may decline, increasing fetal stress. This can trigger passage of meconium in utero and aspiration during delivery, especially with late decelerations suggesting uteroplacental insufficiency.
Rationale for incorrect choices:
- Intraventricular hemorrhage: This condition is typically associated with preterm infants due to fragile cerebral vasculature. A post-term newborn is not at increased risk for IVH.
- Bronchopulmonary dysplasia: BPD is a chronic lung disease most often seen in premature infants requiring prolonged mechanical ventilation and oxygen therapy. It is not a common concern for post-term infants.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. Cheyne-Stokes respirations: This irregular breathing pattern is common in clients nearing end of life due to neurologic decline. It is not a direct indicator of pain and does not necessarily require pain medication unless associated with distress.
B. Restlessness: Restlessness in a palliative care client often signals unrelieved pain, discomfort, or anxiety. It is a nonverbal cue frequently observed in clients unable to communicate pain and should prompt consideration of analgesia.
C. Mottled skin: Mottling is a sign of reduced perfusion and impending death. It reflects circulatory changes but does not directly indicate pain or warrant pain medication unless accompanied by other signs of distress.
D. Constricted pupils: Pupil constriction may result from certain medications (e.g., opioids) or brainstem pressure but is not a reliable sign of pain. It does not, by itself, indicate a need for analgesic intervention.
Correct Answer is B
Explanation
Rationale:
A. Obtaining the initial assessment of assigned clients: Initial assessments require nursing judgment and are part of the nursing process, which cannot be delegated to assistive personnel. Only licensed nurses may perform comprehensive initial assessments.
B. Changing a nonsterile dressing: This is a routine and predictable task that does not require clinical judgment and can be safely delegated to assistive personnel, depending on facility policy and the client’s condition.
C. Interpreting a client's diagnostic laboratory results: Interpretation of lab values requires analysis and clinical decision-making, which are nursing responsibilities. Assistive personnel are not licensed to interpret or evaluate clinical data.
D. Educating a client and family members on home care: Client education involves assessing understanding, using clinical knowledge, and adapting teaching methods, functions reserved for licensed nurses, not assistive personnel.
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