Choice A rationale

Temperature instability, particularly hypothermia, is a significant indicator of neonatal hypoglycemia. Glucose is the primary metabolic fuel for thermogenesis, and its deficiency impairs the infant's ability to maintain core body temperature. The normal newborn temperature range is typically 36.5°C to 37.5°C (97.7°F to 99.5°F).

Choice B rationale

Acrocyanosis, a bluish discoloration of the hands and feet, is a common and usually benign finding in newborns, especially in the first 24-48 hours, due to immature peripheral circulation. It does not directly indicate hypoglycemia; rather, it reflects normal physiological adaptation to extrauterine life.

Choice C rationale

Jitteriness, or tremors, is a classic neurological sign of hypoglycemia in newborns. The central nervous system is highly dependent on glucose for energy, and insufficient glucose supply can lead to neuronal excitability and involuntary muscle movements. This is often an early and prominent symptom.

Choice D rationale

Hypotonia, characterized by decreased muscle tone and floppiness, can be a symptom of severe or prolonged hypoglycemia. Glucose is essential for proper neuromuscular function, and its deprivation can impair nerve impulse transmission and muscle contraction, leading to reduced muscle resistance to passive movement.

Choice E rationale

Abdominal distention is typically associated with gastrointestinal issues such as feeding intolerance, bowel obstruction, or necrotizing enterocolitis. It is not a direct or common manifestation of hypoglycemia in newborns. Hypoglycemia primarily affects metabolic and neurological systems.

Choice A rationale

While monitoring vital signs (temperature, heart rate, and blood pressure) is important for overall maternal assessment, in the context of strong contractions and reported nausea/urge to defecate, these specific vital signs are not the immediate priority for identifying the most critical complication. Normal temperature is 36.5-37.5°C, heart rate 60-100 bpm, blood pressure 90/60 to 120/80 mmHg.

Choice B rationale

The client's symptoms (strong contraction, nausea, urge to defecate) strongly suggest the second stage of labor, specifically an urge to push. The highest priority is to determine the fetal heart rate in relationship to the contraction, as this immediate assessment evaluates fetal well-being and detects potential distress, like late decelerations, indicating uteroplacental insufficiency.

Choice C rationale

Examining vaginal discharge for meconium is important if there are signs of fetal distress, but assessing the fetal heart rate pattern in relation to contractions directly provides real-time information about fetal oxygenation and is therefore the immediate priority when assessing labor progress with these symptoms.

Choice D rationale

Performing a vaginal examination to assess labor progress is a crucial step to confirm cervical dilation and fetal descent. However, before internal examination, ensuring fetal well-being through external monitoring of the fetal heart rate during contractions is paramount, especially with the client's reported symptoms suggesting advanced labor.

Choice A rationale

Consuming 27 mg of iron daily is within the recommended intake for pregnant individuals, which is typically around 27 mg per day. Iron is crucial for fetal growth and preventing maternal anemia, and this intake level supports healthy pregnancy outcomes, indicating a reduced risk factor.

Choice B rationale

Consuming 300 mg of caffeine daily is considered a high-risk lifestyle factor during pregnancy. High caffeine intake is associated with an increased risk of miscarriage, preterm birth, and low birth weight infants. The recommended limit for pregnant individuals is generally below 200 mg per day to mitigate these risks.

Choice C rationale

Consuming 3 L (101 oz) of water daily is a healthy practice during pregnancy. Adequate hydration is essential for maintaining blood volume, amniotic fluid levels, and preventing constipation and urinary tract infections. This intake level supports maternal and fetal health.

Choice D rationale

Consuming 400 mcg of folate daily is the recommended intake for pregnant individuals, particularly in the periconceptional period. Folic acid supplementation significantly reduces the risk of neural tube defects in the fetus, promoting a healthy pregnancy outcome and indicating a reduced risk factor.

Choice A rationale

900 mL of urine output since birth (9 hours postpartum) translates to an average of 100 mL/hour. A normal urine output is typically 0.5 to 1 mL/kg/hour, which is usually greater than 30 mL/hour for adults. This indicates adequate renal perfusion and fluid balance rather than deficit.

Choice B rationale

A temperature of 37.6° C (99.6° F) is considered a low-grade fever. While it could be an early sign of infection, it is not a direct indicator of fluid volume deficit. Normal postpartum temperature may slightly increase due to dehydration or exertion during labor but usually remains below 38°C (100.4°F).

Choice C rationale

Reports of excessive sweating could be a compensatory mechanism for fever or a response to hormonal changes postpartum, but it is not a primary indicator of fluid volume deficit. In fact, excessive sweating can contribute to fluid loss, but it is not the most definitive sign.

Choice D rationale

A blood pressure of 80/55 mm Hg, particularly with a quantitative blood loss of 1200 mL, is a significant indicator of fluid volume deficit, specifically hypovolemic shock. Normal postpartum blood pressure is usually similar to pre-pregnancy levels (e.g., 90/60 to 120/80 mmHg). The low blood pressure reflects inadequate circulatory volume compromising tissue perfusion.

Choice A rationale

The primary goal of epidural analgesia is to provide effective pain relief while allowing the client to maintain some sensation, particularly pressure, which indicates the epidural is blocking nociceptive pain signals effectively without completely eliminating proprioceptive awareness. This selective blockade allows the client to feel contractions, facilitating pushing efforts, while minimizing pain perception by blocking transmission of pain impulses via spinal nerves.

Choice B rationale

Bladder distention is a common side effect of epidural analgesia, resulting from the blockade of parasympathetic nerve fibers innervating the bladder, which can impair the micturition reflex. While it indicates the epidural's systemic effect, it is an adverse effect requiring intervention, such as catheterization, rather than a direct indicator of effective pain management.

Choice C rationale

A decrease in systolic blood pressure by 20 mm Hg, or more, is a common adverse effect of epidural analgesia, caused by sympathetic blockade, leading to vasodilation and subsequent peripheral pooling of blood. While it demonstrates the systemic absorption and action of the anesthetic, it signifies a complication requiring management, not an indicator of effective pain relief for labor.

Choice D rationale

Inability to move legs or feet suggests a dense motor blockade, which can occur with epidural analgesia but is not the desired outcome for labor. While a degree of motor weakness may be present, complete motor paralysis can hinder effective pushing during the second stage of labor and is usually avoided to allow for maternal participation in the birth process.

Choice A rationale

Immediate cesarean birth is generally not indicated for intrauterine fetal demise unless there are maternal complications, such as hemorrhage or infection, or if the client has a prior uterine scar that contraindicates vaginal birth. Cesarean section carries higher risks for the mother compared to vaginal delivery and is usually reserved for specific obstetrical indications.

Choice B rationale

Methotrexate is an antimetabolite medication primarily used in the management of ectopic pregnancy or gestational trophoblastic disease due to its cytotoxic effects on rapidly dividing cells. It is not indicated for the induction of labor or expulsion of a fetus in cases of intrauterine fetal demise as it does not stimulate uterine contractions effectively for this purpose.

Choice C rationale

In cases of intrauterine fetal demise at 36 weeks of gestation, scheduled induction of labor is the most common and generally recommended treatment option. This approach allows for planned delivery, reduces the psychological burden of carrying a deceased fetus, and minimizes the risk of complications such as coagulopathy for the mother, typically occurring after prolonged retention.

Choice D rationale

Dilation with suction curettage is a procedure typically used for early pregnancy termination or management of miscarriage in the first or early second trimester. At 36 weeks of gestation, the size of the fetus and uterus makes this procedure unsafe and inappropriate for delivery of a deceased fetus, posing significant risks of uterine perforation or hemorrhage.

Choice A rationale

Nausea, commonly known as "morning sickness," is a very common and normal physiological response during the first trimester of pregnancy, often attributed to hormonal changes, particularly rising levels of human chorionic gonadotropin (hCG) and estrogen. While uncomfortable, it does not typically indicate a need for a registered dietitian referral unless it leads to significant weight loss or hyperemesis gravidarum.

Choice B rationale

A 4.5 kg (10 lb) weight gain by 12 weeks of gestation is considered excessive for the first trimester. The recommended weight gain during the first trimester is typically 0.5 to 2 kg (1 to 4.5 lb). Such rapid weight gain can indicate an imbalanced diet or underlying nutritional issues that warrant evaluation and guidance from a registered dietitian to optimize maternal and fetal health.

Choice C rationale

Taking a multivitamin daily, especially one formulated for prenatal use, is a positive health behavior during pregnancy. Prenatal vitamins typically contain essential nutrients like folic acid and iron, which are crucial for fetal development and maternal health, reducing the risk of neural tube defects and iron deficiency anemia. This indicates appropriate nutritional supplementation, not a need for referral.

Choice D rationale

Constipation is a common complaint during pregnancy, often due to hormonal changes, such as increased progesterone, which slows gastrointestinal motility, and pressure from the growing uterus on the bowels. Eating prunes is a natural and effective dietary strategy to manage constipation, as they are a good source of fiber, promoting bowel regularity. This is a healthy coping mechanism and does not necessitate a dietitian referral.

Choice A rationale

Acrocyanosis, characterized by bluish discoloration of the hands and feet, is a common and usually benign finding in newborns, especially shortly after birth due to immature peripheral circulation. It does not typically indicate neonatal abstinence syndrome, which is a neurological and systemic hyperexcitability response to opioid withdrawal.

Choice B rationale

Hypotonia, or decreased muscle tone, is generally a sign of central nervous system depression or neuromuscular disorder. In contrast, newborns with neonatal abstinence syndrome typically exhibit hypertonia, characterized by increased muscle tone, tremors, and hyperreflexia, due to the overstimulation of the central nervous system following cessation of maternal opioid exposure.

Choice C rationale

An exaggerated Moro reflex, characterized by an overly robust and prolonged startle response, is a common manifestation of central nervous system irritability seen in newborns experiencing neonatal abstinence syndrome. This hyperreflexia is a direct result of the withdrawal symptoms, indicating an overactive nervous system in response to the absence of the previously supplied opioid.

Choice D rationale

Tachypnea, or rapid breathing, is a frequent finding in newborns with neonatal abstinence syndrome. This symptom is often attributed to central nervous system irritability and increased metabolic demand associated with withdrawal, leading to respiratory distress. The respiratory rate often exceeds the normal range of 30-60 breaths per minute.

Choice E rationale

A shrill-pitched cry, often described as inconsolable or high-pitched, is a classic and distinctive symptom of neonatal abstinence syndrome. This abnormal cry pattern is indicative of central nervous system irritation and dysregulation, reflecting the newborn's discomfort and hyperirritability stemming from opioid withdrawal. This cry often differs from a typical hunger or discomfort cry.

Choice A rationale

Dark and concentrated urine in an infant indicates inadequate hydration, which can be a sign of insufficient milk intake during breastfeeding. Well-hydrated infants, receiving adequate breast milk, typically produce urine that is pale yellow and dilute, not dark and concentrated. This reflects proper kidney function and fluid balance.

Choice B rationale

After effective breastfeeding, the breasts should feel softer and less engorged, not firm. The firmness before feeding is due to milk accumulation within the mammary glands. As the infant removes milk, the pressure decreases, leading to a softer breast texture, indicating successful milk transfer.

Choice C rationale

A tugging sensation during breastfeeding is a normal and expected physiological sign. This sensation results from the baby's effective latch and negative pressure creation, which draws milk from the milk ducts into the baby's mouth. It signifies proper milk ejection and efficient feeding.

Choice D rationale

Two to three wet diapers in a 24-hour period for a 5-day-old infant is indicative of insufficient fluid intake. A well-hydrated newborn at this age, receiving adequate breast milk, should typically have six to eight wet diapers per 24 hours, reflecting sufficient hydration and milk transfer.

Choice A rationale

A distended bladder upon palpation indicates urinary retention, meaning the client is unable to effectively empty their bladder. This is a sign of ineffective voiding and can lead to complications such as urinary tract infections or uterine displacement. Normal bladder should not be distended after voiding.

Choice B rationale

The uterine fundus being 2 cm above the umbilicus is a sign of uterine displacement due to a full bladder. A full bladder prevents the uterus from contracting and descending properly, interfering with involution. Effective voiding allows the uterus to return to its normal post-delivery position.

Choice C rationale

Not feeling the urge to urinate suggests nerve damage or a decreased bladder sensation, which is not a sign of effective voiding. A healthy bladder function includes the sensation of fullness prompting the urge to void, which is crucial for timely and complete bladder emptying.

Choice D rationale

Urinating only 30 mL/hr is considered oliguria, an abnormally low urine output. Normal urine output for an adult is generally 30 to 60 mL/hr, but post-catheter removal, a good indicator of effective voiding is consistent, larger volume urination, typically at least 150-200 mL per void.