A nurse in the newborn unit is caring for several infants.
Which of the following situations requires the nurse's immediate attention and intervention?
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 12 hours post-delivery and has a temperature of 37.5°C (99.5°F)
A newborn who is 24 hours post-delivery and has not passed meconium
The Correct Answer is D
Choice A rationale
A newborn typically begins to void within 24 hours after birth, so not voiding within this time frame is not immediately concerning.
Choice B rationale
Acrocyanosis, or bluish discoloration of the hands and feet, is common in newborns, especially within the first few hours after birth. It is a normal finding and does not require immediate intervention.
Choice C rationale
A temperature of 37.5°C (99.5°F) is within the normal range for a newborn. Therefore, this does not require immediate attention.
Choice D rationale
Newborns typically pass meconium, the first stool, within 24 to 48 hours after birth. If a newborn has not passed meconium within 24 hours, it could indicate a problem such as meconium ileus, a complication of cystic fibrosis, or other conditions that might obstruct the bowel. This situation requires immediate attention and intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
At the level of the umbilicus. After a vaginal delivery, the nurse should expect to find the uterine fundus at the level of the umbilicus.
Correct Answer is B
Explanation
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