A nurse in the newborn nursery is caring for a group of newborns.
Which of the following newborns requires immediate attention?
A newborn who is 24 hours post-delivery and has not voided.
A newborn who is 18 hours post-delivery and has acrocyanosis.
A newborn who is 24 hours post-delivery and has not passed meconium.
A newborn who is 12 hours post-delivery and has a temperature of 100.5 degrees
The Correct Answer is D
Choice A rationale
While voiding is expected, the normal range for the first void is typically within the first 24 to 48 hours of life. A newborn not voiding at exactly 24 hours warrants continued monitoring, but it is not an immediate emergency unless there are other signs of distress or an obvious obstruction.
Choice B rationale
Acrocyanosis is a normal, transient condition in the newborn characterized by a bluish discoloration of the hands and feet due to sluggish peripheral circulation. It is common for up to 24 hours after birth and does not require immediate intervention, only ongoing assessment to ensure central color is pink.
Choice C rationale
Most healthy newborns pass meconium, the first stool, within the first 24 hours of life, with almost all passing it by 48 hours. A lack of meconium passage at 24 hours requires investigation for potential intestinal issues, such as Hirschsprung's disease or meconium plug, but an elevated temperature signals more acute distress.
Choice D rationale
A temperature of 100.5 degrees F (38.1 degrees C) in a newborn, which is above the normal range (typically 97.7 to 99.5 degrees F or 36.5 to 37.5 degrees C), is a serious finding. Newborns are susceptible to rapid temperature changes, and hyperthermia can indicate sepsis, dehydration, or environmental issues requiring immediate assessment and intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Low birth weight is a classification based solely on absolute weight, defined as a birth weight less than 2,500 grams (5.5 pounds), regardless of gestational age. This newborn weighs 3,500 grams, which is significantly above the threshold for low birth weight, so this classification is incorrect. Low birth weight infants require specialized care due to potential prematurity or intrauterine growth restriction.
Choice B rationale
Appropriate for gestational age (AGA) is defined as a newborn whose birth weight falls between the 10th and 90th percentiles for their specific gestational age. This newborn is at 39 weeks of gestation and weighs 3,500 grams, which places the weight at the 70th percentile, fitting squarely within the AGA category. Infants in this category generally have the lowest risk of adverse outcomes.
Choice C rationale
Small for gestational age (SGA) is a classification given to a newborn whose birth weight is below the 10th percentile for their specific gestational age. This neonate is in the 70th percentile, indicating a healthy size relative to the gestational age of 39 weeks, therefore the SGA classification is not applicable in this clinical scenario. SGA infants are at risk for hypoglycemia and hypothermia.
Choice D rationale
Large for gestational age (LGA) is defined as a newborn whose birth weight is above the 90th percentile for their specific gestational age. Since this newborn's weight is at the 70th percentile, it does not meet the criteria for LGA. LGA newborns, especially those >4000 grams, are at increased risk for birth trauma and hypoglycemia.
Correct Answer is C
Explanation
Choice A rationale
Hemophilia A is a hereditary bleeding disorder caused by a deficiency in coagulation factor VIII. Administering factor X would not correct the underlying deficiency responsible for the child's impaired clot formation, as factor X is a different component of the coagulation cascade and is deficient in factor X deficiency, a distinct disorder.
Choice B rationale
Iron is a crucial component of hemoglobin, and an intravenous infusion of iron is indicated for treating severe iron deficiency anemia. While a child with repeated bleeding episodes could develop anemia, the immediate priority for an acute joint or soft tissue bleed in hemophilia is replacing the deficient clotting factor to stop the hemorrhage.
Choice C rationale
The immediate and definitive treatment for acute bleeding episodes in a child with hemophilia A is the intravenous infusion of the deficient clotting factor, which is factor VIII. Prompt administration helps to control the bleeding into the joint (hemarthrosis), preventing long-term damage and pain.
Choice D rationale
Intramuscular injections are strongly contraindicated in individuals with hemophilia because they pose a significant risk of causing a deep, painful hematoma due to uncontrolled bleeding into the muscle tissue. Iron administration, if needed, should be given orally or intravenously, but not intramuscularly.
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