Try Naxlex NCLEX-RN (Free-Trial)

Which of the following findings in the newborn's electronic medical record (EMR) are risk factors for the newborn to develop a complication? (Select all that apply.)

Weight.

Type of birth.

Apgar scores.

Gestational age.

Heart sounds.

Length.

Answer and Explanation

Correct Answer : B,C,D

Choice A rationale

The newborn's weight is an important metric used to assess appropriate growth. While deviations (e.g., small for gestational age or large for gestational age) are risk factors, the mere recording of the weight itself in the EMR is a standard measurement, not inherently a risk factor. It becomes a risk factor only when the measurement falls outside the expected range for the newborn's gestational age.

Choice B rationale

The type of birth (e.g., vaginal, Cesarean section) is a risk factor for complications. Cesarean birth, especially without labor, is associated with an increased risk of transient tachypnea of the newborn (TTN) due to retained fetal lung fluid. Conversely, a prolonged or operative vaginal birth can increase the risk of birth trauma, suggesting the type of birth itself introduces specific complication risks.

Choice C rationale

Apgar scores are a rapid assessment of five physiological signs (Appearance, Pulse, Grimace, Activity, Respiration) at one and five minutes of life. A low Apgar score (typically ≤ 7 at five minutes) is a significant and immediate indicator of neonatal distress and a strong risk factor for long-term neurological complications, necessitating prompt and potentially intensive resuscitation.

Choice D rationale

Gestational age is a primary determinant of neonatal maturity and viability. Preterm birth (less than 37 weeks) is a major risk factor for complications, including respiratory distress syndrome (due to surfactant deficiency), thermoregulation difficulties, and developmental issues. Post-term birth (over 42 weeks) is also a risk for placental insufficiency and meconium aspiration.

Choice E rationale

The recording of heart sounds in the EMR is part of a standard newborn physical assessment. The presence of a normal finding (e.g., regular rhythm, no murmurs) is a sign of health, not a risk factor. An abnormal finding, such as a persistent murmur suggestive of a congenital heart defect, would be the risk factor, but the standard documentation is just a physiological assessment.

Choice F rationale

The newborn's length is a standard anthropometric measurement, assessing overall growth and proportional development. Like weight, recording the length itself is a standard parameter, not a risk factor. It only becomes clinically significant as an indicator of an underlying issue if it is disproportionate or falls significantly outside the expected percentile range for the newborn's gestational age.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A rationale

The Lamaze technique for childbirth preparation utilizes conditioned responses to cope with labor pain, which includes specific signals from the coach, a learned response (like a specific breathing pattern), and relaxation techniques. This approach aims to reduce the perception of pain by focusing attention and promoting muscular release through psychoprophylaxis.

Choice B rationale

Using tennis balls on the sacral area to lean against is a non-pharmacological pain relief technique, but it's a form of counter-pressure applied to the lower back, often effective for back labor, not an instruction specific to the technique of acupressure. Counter-pressure helps to relieve the referred pain caused by the fetus's occiput pressing against the sacrum.

Choice C rationale

Using light, rhythmic strokes on the abdomen, known as effleurage, along with rhythmic breathing, is a touch/massage technique often taught in childbirth classes. It provides a distracting sensory input and promotes relaxation, but it is not the specific method for applying acupressure, which involves sustained pressure on specific body points.

Choice D rationale

Immersing oneself in a tub of warm water is hydrotherapy, a non-pharmacological technique used to relax muscles and reduce pain perception during labor. The warmth promotes vasodilation and aids in relaxation, providing a soothing environment. This method is distinct from the localized pressure application of acupressure.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}

Explanation

Rationale for correct answers: Transient hypoglycemia is common in the first hours of life, especially in macrosomic infants due to maternal hyperglycemia-induced fetal hyperinsulinemia. Blood glucose <40–45 mg/dL is abnormal; this newborn had 35 mg/dL initially, improved to 50 mg/dL after feeding. Symptoms like jitteriness, abnormal cry, and mild hypotonia resolved post-breastfeeding. Breastfeeding provides lactose, which is hydrolyzed to glucose and galactose, correcting hypoglycemia physiologically. Early feeding is first-line for asymptomatic or mildly symptomatic neonates with glucose >25 mg/dL.

Rationale for incorrect Response 1 options: Signs of infection (e.g., temperature instability, poor feeding, lethargy) may overlap with hypoglycemia but require systemic signs and lab confirmation. This newborn improved with feeding and had no fever, tachypnea, or leukocytosis. Respiratory distress presents with grunting, nasal flaring, retractions, and desaturation. The newborn’s respiratory rate was normal (45/min), no distress signs noted. Hyperbilirubinemia manifests as jaundice, typically after 24 hours. No yellowing of skin or sclera was reported; phototherapy is not indicated.

Rationale for incorrect Response 2 options: Administer antibiotics is appropriate for suspected sepsis, not isolated hypoglycemia. No infectious signs or risk factors were present. Provide oxygen support is reserved for respiratory compromise. The newborn had stable vitals and no hypoxia. Initiate phototherapy treats elevated bilirubin. No bilirubin levels or jaundice signs were documented.

Take-home points:

Transient neonatal hypoglycemia is common in macrosomic infants due to hyperinsulinemia.
Early breastfeeding is the preferred intervention for mild hypoglycemia with stable vitals.
Differentiate hypoglycemia from sepsis and respiratory distress using targeted clinical signs.
Phototherapy is reserved for hyperbilirubinemia; not indicated without jaundice or elevated bilirubin.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Which of the following findings in the newborn's electronic medical record (EMR) are risk factors for the newborn to develop a complication? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a prenatal clinic is reinforcing teaching with a group of women about the use of acupressure to relieve discomfort during labor. Which of the following instructions should the nurse include in the teaching?

Correct Answer is A

Explanation

Exhibits A nurse on the labor and delivery unit is continuing to assist in the care of a newborn. Complete the following sentence by using the lists of options. Because the newborn is exhibiting dropdownthe nurse should plan todropdown.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}

Explanation

Exhibits The nurse is assisting in the initiation of phototherapy. For each nursing action, specify if the action is indicated or not indicated for the newborn.

The nurse reinforces teaching regarding newborn hypoglycemia. Which of the following client statements indicate understanding of newborn hypoglycemia? Select all that apply.

A nurse is collecting data from a newborn who has an infection of Candida albicans. Which of the following findings should the nurse expect?

A nurse is caring for a client who is 10 hours postpartum following a vaginal delivery and reports discomfort at the episiotomy site. Which of the following actions should the nurse take?

A nurse is reinforcing teaching about the correct use of infant car seats with the parent of a newborn. Which of the following statements by the parent indicate an understanding of the teaching?

A nurse is reinforcing teaching about travel with a client who is pregnant. Which of the following instructions should the nurse include?

A nurse is reinforcing teaching with the mother of a newborn about the proper use of a bulb syringe for suctioning. Which of the following instructions should the nurse include in the teaching?

A nurse is caring for a client in an antepartum clinic following a maternal serum alpha-fetoprotein screening. The nurse should recognize that an elevated alpha-fetoprotein level is suggestive of which of the following?