A newborn nurse is called to attend a delivery of a G2 T0 P1 A0 L1 patient at 10cm/100%/+4 station.
The mother has had minimal prenatal care during this pregnancy and thinks she is 38 weeks gestation.
The Labor and Delivery nurse states the only significant issues during labor are: Spontaneous Rupture of Membranes (SROM) 19 hours ago, clear.
Vital signs are stable.
Required augmentation with Pitocin for the past 10 hours.
The patient experienced a 20-minute episode of uterine tachysystole 2 hours ago.
Pitocin was turned off, the patient was turned, an intravenous bolus was given, and oxygen was started, and the uterine tachysystole resolved.
The Fetal Heart Rate (FHR) during that time had a prolonged deceleration lasting 4 minutes but returned to the baseline of 140 with intrauterine resuscitative measures.
The FHR is currently 145, with moderate variability, accelerations, and early decelerations present.
The infant is transported to the nursery for Transitory Tachypnea of the Newborn (TTN). You explain to the patient that TTN is thought to occur as a result of:
The prolonged decelerations the baby experienced in labor.
Delayed absorption of fetal lung fluid.
Hypoinflation of the lungs.
Result of the newborn aspirating meconium during delivery.
The Correct Answer is B
Choice A rationale
Prolonged decelerations, a temporary decrease in Fetal Heart Rate (FHR), primarily suggest transient fetal hypoxemia or acidosis, which could lead to central nervous system depression or potential organ damage, but there is no direct scientific link establishing this as the primary etiology for delayed fluid absorption leading to Transitory Tachypnea of the Newborn (TTN).
Choice B rationale
Transitory Tachypnea of the Newborn (TTN) is scientifically attributed to the delayed or incomplete clearance of fetal lung fluid after birth. Normally, the transition from intrauterine life involves a shift from fluid secretion to absorption by alveolar epithelial sodium channels. Delayed absorption leads to residual fluid in the lungs, causing pulmonary edema and impaired gas exchange, manifesting as tachypnea.
Choice C rationale
Transitory Tachypnea of the Newborn (TTN) is characterized by residual fluid leading to pulmonary interstitial edema, which results in hyperinflation and air trapping distal to the fluid-filled airways, not hypoinflation. The fluid impairs gas exchange and increases lung compliance, but the overall presentation is one of increased respiratory effort due to retained fluid.
Choice D rationale
Meconium Aspiration Syndrome (MAS) is a distinct respiratory distress condition caused by the aspiration of meconium-stained amniotic fluid, leading to airway obstruction, chemical pneumonitis, and surfactant inactivation, causing severe respiratory distress. This condition is mechanistically different from TTN, which is due to delayed fluid absorption.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
While maternal iron supplementation can sometimes lead to dark green or black stools in the mother, it does not typically cause the meconium stool that is characteristic of a newborn's first bowel movements. Meconium is composed of substances ingested in utero, such as amniotic fluid, lanugo, and intestinal secretions, and its appearance is a normal physiological process, unrelated to prenatal iron use.
Choice B rationale
Black, sticky stool in the first few days of life is characteristically meconium, not an indication of dehydration. Dehydration in a newborn, which can occur if feeding is inadequate (e.g., normal serum sodium range 135-145 mEq/L), would typically manifest with signs such as decreased urine output (less than 1-2 mL/kg/hr), sunken fontanelles, and poor skin turgor.
Choice C rationale
This is the appropriate response because meconium is the first stool passed by a newborn, typically within the first 24-48 hours. It is thick, black, and sticky/tar-like in consistency, composed of materials ingested during the fetal period. This finding confirms a patent anus and normal intestinal motility, indicating adequate physiological transition.
Choice D rationale
While blood in the stool, medically termed hematochezia or melena depending on the source, can be caused by conditions like a cow's milk protein allergy, meconium is not due to blood and is a normal transitional stool. An allergy-related bloody stool is usually loose, red-streaked, or mixed with mucus, and generally occurs later as the infant ingests breast milk or formula. —.
Correct Answer is D
Explanation
Choice A rationale
A hemorrhoid is a swollen, inflamed vein in the rectum or anus, which can cause pain and pressure, especially after the strenuous process of childbirth and pushing. While possible, the combination of increasing perineal pain, rectal pressure, and inability to void following a forceps delivery and a third-degree laceration is more indicative of a deeper tissue injury or collection of blood than an external or internal hemorrhoid alone.
Choice B rationale
A bladder infection, or cystitis, typically presents with symptoms such as dysuria (painful urination), urgency, frequency, and sometimes hematuria, often appearing later in the postpartum course. While urinary retention is a risk after birth trauma, an infection is less likely to be the immediate cause of acute, rapidly increasing rectal pressure and severe perineal pain just three hours after delivery.
Choice C rationale
Uterine atony is the failure of the uterus to contract sufficiently after childbirth, which is the most common cause of postpartum hemorrhage. The assessment states the fundus is firm and the lochia is moderate without clots, which rules out significant uterine atony as the primary issue causing the localized, intense perineal and rectal discomfort.
Choice D rationale
A vaginal or vulvar hematoma is a collection of blood in the connective tissue, often resulting from trauma during delivery, especially with forceps, episiotomy, and deep lacerations. Its rapid expansion causes severe, unremitting, localized pain, rectal pressure (from mass effect), and can lead to urinary retention by distorting the urethra, which perfectly aligns with the patient's acute symptoms. —.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.