A baby is born with a diaphragmatic hernia. Which of the following signs/symptoms would the nurse likely observe in the delivery room?
Projectile vomiting.
High-pitched crying.
Respiratory distress.
Fecal incontinence.
The Correct Answer is C
Choice A rationale
Projectile vomiting is not a typical symptom of diaphragmatic hernia. This condition primarily affects respiratory function due to lung compression by abdominal organs in the chest cavity.
Choice B rationale
High-pitched crying is not a hallmark symptom of diaphragmatic hernia. The condition primarily presents with respiratory distress due to lung underdevelopment and organ displacement.
Choice C rationale
Respiratory distress occurs due to lung compression and underdevelopment caused by abdominal organs herniating into the chest cavity. This is a primary symptom observed in diaphragmatic hernia cases.
Choice D rationale
Fecal incontinence is unrelated to diaphragmatic hernia. The condition primarily impacts respiratory function due to the displacement of abdominal organs into the thoracic cavity.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Preterm infants lack coordination for sucking, swallowing, and breathing until approximately 32-34 weeks' gestation. Gavage feeding prevents aspiration by bypassing the immature oral motor mechanisms required for safe oral feeding.
Choice B rationale
Preterm infants can digest milk due to functional gastrointestinal enzymes. Digestive immaturity relates more to delayed gastric emptying rather than the inability to process nutrients, which is managed with small frequent feeds.
Choice C rationale
Monitoring intake is crucial for growth and hydration, but gavage feeding primarily addresses feeding immaturity, not intake measurement. Accurate intake can be monitored through oral feeds with supplemental measurements.
Choice D rationale
Gavage feeding does not directly prevent thrush. Thrush prevention involves oral hygiene and immune support rather than feeding methods, as thrush may still occur regardless of tube feeding or oral intake.
Correct Answer is A
Explanation
Choice A rationale
Urine output of 40 mL in 8 hours indicates oliguria, suggesting inadequate renal perfusion. Normal urine output is 30 mL/hour or greater. This could signify hypovolemia or renal compromise post-hemorrhage.
Choice B rationale
A drop in hematocrit of 2% may be expected postpartum and is not immediately concerning unless accompanied by hemodynamic instability or symptoms of anemia like dizziness or fatigue.
Choice C rationale
A 2 lb weight decrease postpartum is normal due to fluid shifts and diuresis. It does not indicate an emergent condition requiring immediate reporting to the obstetrician.
Choice D rationale
A pulse rate of 68 beats per minute is within the normal adult range of 60 to 100 beats per minute and is not typically concerning post-delivery.
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