A nurse is admitting an 8-hour-old, term newborn following a cesarean birth. The nurse observes that the newborn’s skin is yellow.
This finding indicates the newborn is experiencing a complication related to which of the following?
Physiologic jaundice.
Maternal/newborn blood group incompatibility.
Maternal cocaine abuse.
Absence of vitamin K. .
The Correct Answer is A
Choice A rationale
Physiologic jaundice is a common condition in newborns, usually appearing between the second and fourth day of life. It is caused by an increase in bilirubin, a substance produced by the breakdown of red blood cells.
Choice B rationale
Maternal/newborn blood group incompatibility can cause jaundice, but it typically appears within the first 24 hours of life.
Choice C rationale
Maternal cocaine abuse can lead to various complications in the newborn, but it does not directly cause jaundice.
Choice D rationale
Absence of vitamin K does not cause jaundice. Vitamin K is given to newborns to prevent bleeding disorders.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Projectile vomiting after feedings is a classic symptom of pyloric stenosis. This occurs because the enlarged pyloric muscle obstructs the passage of food from the stomach to the small intestine.
Choice B rationale
Absent bowel sounds are not typically associated with pyloric stenosis. While this condition affects the gastrointestinal tract, it does not typically cause a complete absence of bowel sounds.
Choice C rationale
Increased sodium levels are not a typical finding in a newborn with pyloric stenosis. In fact, these infants may have low sodium levels due to vomiting.
Choice D rationale
A golf ball-sized mass over the left quadrant is not a typical finding in a newborn with pyloric stenosis. The classic physical examination finding in pyloric stenosis is a palpable “olive-like” mass in the right upper quadrant of the abdomen.
Correct Answer is C
Explanation
The correct answer is Choice C.
Choice A rationale: A respiratory rate of 16/min is within the normal range for an adult and does not indicate immediate concern.
Choice B rationale: A headache can be a symptom of preeclampsia, but it is not as immediate a concern as the other options unless it is severe or accompanied by other symptoms.
Choice C rationale: A urinary output of 40 ml in 2 hours is significantly below the normal range. Oliguria (low urine output) can be a sign of renal impairment and magnesium toxicity, which requires immediate reporting to the healthcare provider.
Choice D rationale: A fetal heart rate of 158/min is within the normal range for a fetus and does not indicate immediate concern.
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