A nurse is admitting a term newborn following a cesarean birth. The nurse observes that the newborn's skin is slightly yellow right after birth. This finding indicates the newborn is experiencing a complication related to which of the following?
Physiological jaundice
Maternal cocaine abuse
Maternal/newborn blood group incompatibility
Absence of vitamin K
The Correct Answer is C
Choice A reason: Physiological jaundice is not the correct answer, as it is a normal and benign condition that occurs in about 60% of term newborns, and usually appears after the first 24 hours of life. Physiological jaundice is caused by the breakdown of fetal hemoglobin and the immature liver function, and resolves within a few days.
Choice B reason: Maternal cocaine abuse is not the correct answer, as it is a maternal risk factor that can cause various complications in the newborn, such as low birth weight, prematurity, intrauterine growth restriction, or congenital anomalies. Maternal cocaine abuse does not cause jaundice in the newborn, unless it leads to hepatic or renal dysfunction.
Choice C reason: Maternal/newborn blood group incompatibility is the correct answer, as it is a maternal-fetal condition that can cause hemolytic disease of the newborn, which is a severe form of jaundice that can appear within the first 24 hours of life. Maternal/newborn blood group incompatibility occurs when the mother's blood type is Rh negative and the newborn's blood type is Rh positive, or when the mother's blood type is O and the newborn's blood type is A or B. The maternal antibodies cross the placenta and attack the newborn's red blood cells, causing hemolysis, anemia, and hyperbilirubinemia.
Choice D reason: Absence of vitamin K is not the correct answer, as it is a nutritional deficiency that can cause hemorrhagic disease of the newborn, which is a bleeding disorder that can occur within the first week of life. Absence of vitamin K is due to the lack of intestinal flora and the low vitamin K content in breast milk, and can cause bleeding in the skin, mucous membranes, or internal organs. Absence of vitamin K does not cause jaundice in the newborn, unless it leads to hepatic or biliary dysfunction.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is B. No special treatment is necessary.
Choice A reason: Prone positioning is not typically recommended for a fractured clavicle in infants. It does not facilitate bone alignment in the case of clavicle fractures and is not part of standard care.
Choice B reason: This is the correct choice because clavicle fractures in newborns generally heal on their own without the need for special treatment. Parents may be instructed to pin the child’s sleeve to the front of their clothing to avoid moving the arm while it heals, but beyond gentle handling, no other special treatment is necessary. In most cases, clavicle fractures in newborns heal very quickly without any problems, and usually, no treatment is required.
Choice C reason: Immobilization and casting are not standard care for newborn clavicle fractures. These fractures typically heal without such interventions, and immobilization with a cast is not needed for these types of injuries in infants.
Choice D reason: While range-of-motion exercises might be beneficial later in the healing process, they are not the primary consideration immediately after the fracture occurs. The initial care plan focuses on gentle handling and comfort for the infant, not on exercises.
Correct Answer is D
Explanation
Choice A reason: Placenta previa is a condition where the placenta covers the cervix partially or completely. It can cause painless vaginal bleeding, but not abdominal pain.
Choice B reason: Prolapsed cord is a condition where the umbilical cord slips through the cervix and protrudes into the vagina or beyond. It can cause fetal distress, but not abdominal pain or vaginal bleeding.
Choice C reason: Incompetent cervix is a condition where the cervix dilates prematurely and painlessly. It can cause preterm labor and delivery, but not abdominal pain or vaginal bleeding.
Choice D reason: Abruptio placentae is a condition where the placenta separates from the uterine wall before delivery. It can cause severe abdominal pain, vaginal bleeding, and fetal distress. It is a medical emergency that requires immediate intervention.
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