A nurse is admitting a full-term baby boy delivered 12 hours ago to the nursery following a cesarean birth.
The nurse observes that the newborn's skin is slightly yellow.
This finding indicates the newborn is experiencing a complication related to which of the following?
Maternal/newborn blood group incompatibility.
Physiologic jaundice.
Maternal cocaine abuse.
Absence of vitamin K. .
The Correct Answer is B
Choice A rationale:
Maternal/newborn blood group incompatibility can lead to jaundice in newborns, but it typically occurs within the first 24 hours of life. In this scenario, the baby is delivered 12 hours ago, and the yellowing of the skin is described as "slight.”. Physiologic jaundice, which occurs in the majority of newborns, typically appears on the second or third day after birth, so this choice is less likely.
Choice B rationale:
Physiologic jaundice is the most likely cause of the slight yellowing of the newborn's skin. It typically appears on the second or third day after birth and is related to the immature liver's inability to efficiently process bilirubin. Physiologic jaundice is a common and self-limiting condition that does not usually require treatment.
Choice C rationale:
Maternal cocaine abuse can lead to various neonatal complications, but it is not typically associated with jaundice. The yellowing of the skin in this scenario is more likely related to another cause.
Choice D rationale:
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Correct Answer is D
Explanation
Choice A rationale: Decreased energy is a common symptom during pregnancy, especially in the first and third trimesters. This is typically due to hormonal changes, increased demands on the body, and changes in sleep patterns. While decreased energy can be uncomfortable, it is usually not a sign of a serious problem and does not require immediate medical attention unless it is severe or accompanied by other concerning symptoms.
Choice B rationale: Urinary frequency is another common symptom during pregnancy, caused by hormonal changes and the growing uterus putting pressure on the bladder. This symptom is usually most noticeable in the first and third trimesters. While it can be inconvenient, it is generally not a cause for concern and does not require a call to the healthcare provider unless it is accompanied by pain or other symptoms suggestive of a urinary tract infection.
Choice C rationale: Mood swings are a frequent occurrence during pregnancy due to hormonal fluctuations. Pregnant individuals may experience a wide range of emotions, from happiness and excitement to anxiety and irritability. While mood swings can be challenging to manage, they are typically not a sign of a serious problem and do not necessitate immediate medical attention unless they are severe and impact daily functioning.
Choice D rationale: Facial edema, or swelling of the face, can be a sign of preeclampsia, a serious condition that can occur during pregnancy. Preeclampsia is characterized by high blood pressure and can lead to complications for both the mother and baby if left untreated. Other signs of preeclampsia can include severe headaches, visual disturbances, and rapid weight gain. If a pregnant individual experiences facial edema, it is important to contact their healthcare provider promptly for evaluation and management.
Correct Answer is A
Explanation
Choice A rationale:
Checking the fetal heart rate pattern is the priority nursing action following an amniotomy. This procedure involves rupturing the amniotic membranes, which can result in changes to the baby's heart rate. It's essential to assess the fetal heart rate to ensure the baby is tolerating the procedure well and to identify any signs of fetal distress promptly.
Choice B rationale:
Evaluating the client for signs of infection is an important step after an amniotomy, but it is not the top priority. The immediate concern is the well-being of the fetus, and assessing the fetal heart rate takes precedence.
Choice C rationale:
Taking the client's temperature is relevant to monitor for infection, but it should not be the first action. Monitoring the fetus's status with a fetal heart rate assessment is more critical in this situation.
Choice D rationale:
Observing the color and consistency of amniotic fluid is a valuable assessment but not the top priority. It can provide information about meconium staining or other issues, but assessing the fetal heart rate is more crucial immediately after the procedure.
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