During an observational experience in labor and delivery, the student nurse recognizes that thick meconium is present in the amniotic ﬂuid. Upon delivery of the newborn, the student nurse understands that there are signs that indicate that the newborn will need resuscitation. These signs are:
Select one:

Central cyanosis and poor tone.

Heart rate of 160 beats per minute and spitting up mucus.

Crying with respirations of greater than 60 breaths per minute.

Blue hands and feet but lips that are slowly pinking up.

Answer and Explanation

The Correct Answer is A

Choice A Reason: Central cyanosis and poor tone. These are signs of hypoxia and asphyxia in newborns, which indicate a need for resuscitation. Central cyanosis means bluish discoloration of the skin or mucous membranes around the mouth, nose, or eyes. Poor tone means limpness or lack of muscle activity.

Choice B Reason: Heart rate of 160 beats per minute and spitting up mucus. These are not signs of hypoxia or asphyxia in newborns, but rather normal findings or minor issues. A normal heart rate for a newborn ranges from 120 to 160 beats per minute. Spitting up mucus may be due to excess secretions or swallowing amniotic ﬂuid, which can be cleared by suctioning or burping.

Choice C Reason: Crying with respirations of greater than 60 breaths per minute. These are not signs of hypoxia or asphyxia in newborns, but rather normal or expected findings. Crying indicates that the newborn has a patent airway and adequate lung expansion. Respirations of greater than 60 breaths per minute may be normal for a newborn in transition or due to transient tachypnea, which usually resolves within a few hours.

Choice D Reason: Blue hands and feet but lips that are slowly pinking up. These are not signs of hypoxia or asphyxia in newborns, but rather a common condition called acrocyanosis. Acrocyanosis means bluish discoloration of the hands and feet due to poor peripheral circulation in response to cold exposure or stress. It does not aﬀect oxygenation or ventilation and usually disappears within 24 to 48 hours after birth.

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Correct Answer is D

Explanation

Choice A Reason: Hyperglycemia and increased appetite. This is an incorrect answer that describes symptoms of diabetes mellitus, not sepsis. Diabetes mellitus is a chronic metabolic disorder where the body cannot produce or use insulin eﬀectively, which results in high blood glucose levels and impaired glucose tolerance. Diabetes mellitus can aﬀect newborns if the mother has pre-existing or gestational diabetes, which can cause macrosomia, hypoglycemia, or congenital anomalies.

Choice B Reason: Increased urinary output and spitting up mucous. This is an incorrect answer that indicates normal or benign conditions, not sepsis. Increased urinary output is a normal finding in newborns, as they eliminate the excess ﬂuid that was accumulated during pregnancy. Spitting up mucous is a common occurrence in newborns, as they clear their airways of amniotic ﬂuid or secretions.

Choice C Reason: Wakefulness and ruddy appearance. This is an incorrect answer that suggests healthy or normal characteristics, not sepsis. Wakefulness is a sign of alertness and responsiveness in newborns, which reﬂects their neurological development and adaptation. Ruddy appearance is a reddish color of the skin that is normal in newborns, especially in term or post-term infants, which indicates adequate oxygenation and hemoglobin levels.

Choice D Reason: Temperature instability and lethargy. This is because temperature instability and lethargy are common signs of sepsis in newborns, which indicate systemic infection and inﬂammation. Sepsis is a life-threatening condition where the body's response to infection causes tissue damage, organ failure, or death. Sepsis can occur in newborns due to maternal, fetal, or neonatal factors, such as chorioamnionitis, premature rupture of membranes, prolonged labor, invasive procedures, or bacterial colonization.

A. Daily weight. B. Consistency of stool. C. Volume of urine output. D. Blood pH.

Correct Answer is D

Explanation

Choice A Reason: Daily weight. This is an incorrect answer that indicates a valid parameter to assess hydration status. Daily weight is a measure of the body mass that can reﬂect changes in ﬂuid balance. Daily weight can help detect ﬂuid loss or gain in premature infants, who are more prone to dehydration or overhydration due to immature renal function and high insensible water loss.

Choice B Reason: Consistency of stool. This is an incorrect answer that indicates a valid parameter to assess hydration status. Consistency of stool is a measure of the texture and form of feces that can reﬂect changes in ﬂuid intake and absorption. Consistency of stool can help identify diarrhea or constipation in premature infants, who are more susceptible to gastrointestinal problems such as necrotizing enterocolitis or feeding intolerance.

Choice C Reason: Volume of urine output. This is an incorrect answer that indicates a valid parameter to assess hydration status. Volume of urine output is a measure of the amount of urine produced and excreted by the kidneys that can reﬂect changes in ﬂuid balance and renal function. Volume of urine output can help monitor hydration status and kidney function in premature infants, who are more vulnerable to ﬂuid overload or deficit and renal impairment.

Choice D Reason: Blood pH. This is because blood pH is a measure of the acidity or alkalinity of the blood, which reﬂects the balance between carbon dioxide and bicarbonate in the body. Blood pH is not a direct indicator of hydration status, which refers to the amount of water and electrolytes in the body. Hydration status can aﬀect blood pH, but blood pH can also be inﬂuenced by other factors such as respiratory or metabolic disorders.

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Naxlex Comprehensive Predictor Exams

Which of the following would the nurse expect to find in a newborn who is developing sepsis? Select one:

Correct Answer is D

Explanation

In caring for the premature infant, the nurse must continually assess hydration status. Parameters to assess would include all of the following except: Select one:

Correct Answer is D

Explanation

A client has been diagnosed with postpartum psychosis. Which of the following actions should the nurse take? Select one:

Assessment of a woman in labor reveals cervical dilation of 3 cm, cervical eﬀacement of 30%, and contractions occurring every 8 to 10 minutes, lasting about 30 seconds. The nurse determines that this client is in: Select one:

When reviewing the causes of late postpartum hemorrhage, which of the following would the nurse identify as the most common cause? Select one:

A woman in her 40th week of pregnancy calls the nurse at the clinic and says she's not sure whether she is in true or false labor. Which statement by the client would lead the nurse to suspect that the woman is experiencing false labor? Select one:

The Mother-Baby nurse is caring for a two hour old newborn who is 36 4/7 weeks gestation. The nurse assesses that the newborn is experiencing tremors (jiteriness). What nursing action has the highest priority? Select one:

A client who is breastfeeding her newborn tells the nurse, "I notice that when I feed him, I feel fairly strong contraction-like pain. Labor is over. Why am I having contractions now?" Which response by the nurse would be most appropriate? Select one:

An infant of a Diabetic Mother (IDM) has a blood glucose of 60 upon admission to the well-baby nursery. Which of the following is an appropriate nursing action? Select one: