Choice A rationale

Hyperbilirubinemia presents with jaundice (yellowing of the skin and eyes) and is caused by excess bilirubin in the blood. It doesn't typically involve a high-pitched cry, increased muscle tone, or projectile vomiting.

Choice B rationale

Neonatal abstinence syndrome occurs in newborns exposed to addictive opiate drugs while in the mother’s womb. Symptoms include high-pitched crying, increased muscle tone, yawning, poor feeding with vomiting, and tachypnea due to drug withdrawal.

Choice C rationale

Respiratory distress syndrome is primarily characterized by breathing difficulties, including rapid, shallow breathing and a grunting sound. Symptoms do not typically include high-pitched cry or projectile vomiting.

Choice D rationale

Necrotizing enterocolitis involves severe inflammation and necrosis of the intestines. Symptoms include abdominal distension, vomiting bile, bloody stools, and apnea but not a high-pitched cry or increased muscle tone.

Choice A rationale

Umbilical cord compression typically results in variable decelerations in the fetal heart rate, not moderate variability or regular accelerations. It can lead to changes in fetal heart rate patterns, but not regular mild contractions.

Choice B rationale

Dysfunctional labor refers to an abnormal labor pattern, including irregular uterine contractions. The described symptoms fit this condition, as they can cause mild pain and be managed by ambulation, showers, and rest.

Choice C rationale

Chorioamnionitis is an infection of the fetal membranes and amniotic fluid, leading to fever, uterine tenderness, and foul-smelling amniotic fluid, not mild contractions and moderate variability in FHR.

Choice D rationale

Iron deficiency anemia in pregnancy can cause fatigue, pallor, and shortness of breath but does not affect uterine contractions or fetal heart rate.

Choice A rationale

Monitoring the newborn's blood pressure does not directly address symptoms like diaphoresis, jitteriness, and lethargy. These symptoms indicate an immediate need to check blood glucose levels for hypoglycemia.

Choice B rationale

Obtaining blood glucose by heel stick is the correct step because diaphoresis, jitteriness, and lethargy in a newborn are classic signs of hypoglycemia. Timely detection and correction of blood glucose levels are critical.

Choice C rationale

Placing the newborn in a radiant warmer might help maintain body temperature but does not address the root cause of the symptoms, which is likely hypoglycemia.

Choice D rationale

Initiating phototherapy is used to treat jaundice (high bilirubin levels) and is not indicated for managing symptoms of hypoglycemia like diaphoresis, jitteriness, and lethargy.

Choice A rationale

Blue coloring of the hands and feet in an 8-hour-old newborn (acrocyanosis) is a common, benign finding as the newborn’s circulatory system adjusts post-birth. It does not require immediate intervention.

Choice B rationale

Small raised pearly spots on the nose (milia) are harmless and common in newborns. They do not necessitate any intervention.

Choice C rationale

An apical heart rate of 140 bpm is within the normal range for newborns and does not require intervention.

Choice D rationale

Nasal flaring and grunting are signs of respiratory distress in a newborn. This condition demands immediate intervention to ensure the newborn’s airway is clear and breathing is adequately supported.

Choice A rationale

G4T1 P1 A1 L2 implies the client has been pregnant 4 times, with 1 term birth, 1 preterm birth, 1 abortion, and 2 living children. This does not include the correct number of pregnancies or abortions for this client.

Choice B rationale

G5T2 P0 A2 L2 indicates 5 pregnancies, 2 term births, no preterm births, 2 abortions, and 2 living children. This does not correctly account for the preterm birth and abortion history provided.

Choice C rationale

G5T1 P1 A2 L2 is the correct answer, as it denotes 5 pregnancies (including the current one), 1 term birth, 1 preterm birth, 2 abortions, and 2 living children, aligning with the client's history.

Choice D rationale

G5T1 P1 A1 L3 indicates 5 pregnancies, 1 term birth, 1 preterm birth, 1 abortion, and 3 living children. The client has only 2 living children, so this is incorrect.

Choice A rationale

Precipitous labor is a rapid labor that typically lasts less than 3 hours. While it can result in trauma and complications, it does not inherently increase the risk for an operative delivery, which is more often related to other factors like fetal distress or failure to progress.

Choice B rationale

Postpartum hemorrhage (PPH) is a significant concern with precipitous labor due to the rapid and forceful contractions that can cause uterine atony, leading to increased bleeding after birth.

Choice C rationale

In a precipitous labor, the rapid delivery can cause vaginal lacerations, not a decreased risk. The swift passage of the baby through the birth canal increases the risk of tears and trauma.

Choice D rationale

Neonatal sepsis is related to infections acquired during delivery but is not specifically linked to the speed of labor. The primary concern in precipitous labor is maternal trauma and hemorrhage, not infection.

Choice A rationale

Severe nausea and vomiting, known as hyperemesis gravidarum, are more commonly associated with high levels of human chorionic gonadotropin (hCG) and are not specific to ectopic pregnancy.

Choice B rationale

While vaginal bleeding can occur in an ectopic pregnancy, it is usually not a large amount. The bleeding in ectopic pregnancy tends to be light and irregular.

Choice C rationale

Uterine enlargement greater than expected for gestational age is typically associated with conditions like molar pregnancy, not ectopic pregnancy, as the pregnancy is located outside the uterus.

Choice D rationale

Unilateral, cramp-like abdominal pain is a classic symptom of ectopic pregnancy as the fertilized egg implants outside the uterus, most commonly in a fallopian tube, causing localized pain.

Choice A rationale

A reaction from an epidural can cause side effects such as hypotension and shivering, but it is not related to tachysystole.

Choice B rationale

When the fetus's heart rate drops below baseline, it is termed bradycardia, not tachysystole. This condition can occur due to various reasons, including cord prolapse or placental insufficiency.

Choice C rationale

Tachysystole is defined as more than five contractions in 10 minutes. This condition can lead to reduced blood flow to the fetus, resulting in fetal distress.

Choice D rationale

Pitocin is a medication used to induce labor and can cause tachysystole, but the administration of Pitocin itself is not the definition of tachysystole. It's the increased frequency of contractions that defines the condition.

Choice A rationale

Acknowledging the client’s feelings provides emotional support and validates her experience. This response opens the door for further discussion and support, which is crucial for emotional well-being.

Choice B rationale

Suggesting future possibilities does not address the client's current emotional state. It may come across as dismissive of her feelings and does not offer the immediate support she needs.

Choice C rationale

While emphasizing the health of the baby is positive, it can also be perceived as dismissive of the client's feelings and her disappointment about the birth experience.

Choice D rationale

Mentioning the resumption of sexual relations shifts the focus away from her emotional needs and can be inappropriate or insensitive in this context, failing to address her disappointment.

Choice A rationale

A rapid pulse is not typically associated with magnesium toxicity. Magnesium toxicity more commonly affects the nervous and muscular systems.

Choice B rationale

Tingling in toes can be a sign of early magnesium sulfate effects but not necessarily toxicity. It may indicate that the medication is starting to affect the nervous system.

Choice C rationale

Cool skin temperature is not a common sign of magnesium toxicity. Symptoms of magnesium toxicity are more related to neuromuscular and respiratory function.

Choice D rationale

Absent deep tendon reflexes are a key indicator of magnesium toxicity. This finding suggests that magnesium levels are high enough to depress neuromuscular function, requiring immediate medical intervention. .