A nurse is assessing a newborn immediately following a vaginal birth.
For which of the following findings should the nurse intervene?
Sternal retractions.
Acrocyanosis.
Molding.
Vernix caseosa.
The Correct Answer is A
Choice A rationale
Sternal retractions indicate increased respiratory effort and can be a sign of respiratory distress in a newborn. This occurs when the infant is struggling to inhale, causing the chest wall to visibly pull inward with each breath due to negative pressure, and requires immediate intervention.
Choice B rationale
Acrocyanosis, characterized by bluish discoloration of the hands and feet, is a common and normal finding in newborns during the first 24 to 48 hours after birth. It is due to immature peripheral circulation and does not typically indicate a need for intervention.
Choice C rationale
Molding is the overlapping of the fetal skull bones during passage through the birth canal. This is a normal adaptation during vaginal birth and typically resolves spontaneously within a few days, thus requiring no intervention.
Choice D rationale
Vernix caseosa is a whitish, cheesy substance covering the skin of many newborns, providing protection and lubrication in utero. Its presence is normal and beneficial, often providing hydration and antimicrobial properties to the skin post-birth.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Consuming 27 mg of iron daily is within the recommended intake for pregnant individuals, which is typically around 27 mg per day. Iron is crucial for fetal growth and preventing maternal anemia, and this intake level supports healthy pregnancy outcomes, indicating a reduced risk factor.
Choice B rationale
Consuming 300 mg of caffeine daily is considered a high-risk lifestyle factor during pregnancy. High caffeine intake is associated with an increased risk of miscarriage, preterm birth, and low birth weight infants. The recommended limit for pregnant individuals is generally below 200 mg per day to mitigate these risks.
Choice C rationale
Consuming 3 L (101 oz) of water daily is a healthy practice during pregnancy. Adequate hydration is essential for maintaining blood volume, amniotic fluid levels, and preventing constipation and urinary tract infections. This intake level supports maternal and fetal health.
Choice D rationale
Consuming 400 mcg of folate daily is the recommended intake for pregnant individuals, particularly in the periconceptional period. Folic acid supplementation significantly reduces the risk of neural tube defects in the fetus, promoting a healthy pregnancy outcome and indicating a reduced risk factor.
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C"}
Explanation
The client is at greatest risk for developing Endometritis as evidenced by the client’s Lochia characteristics.
Rationale for correct answers:
Endometritis is a postpartum uterine infection commonly occurring after cesarean birth due to ascending bacterial contamination. The client’s foul-smelling lochia is a hallmark sign, indicating infection of the uterine lining. Normally, lochia is odorless and changes from red to serous and then to white over weeks postpartum. The elevated WBC count (18,000/mm³; normal 5,000–15,000/mm³) supports infection but is nonspecific. The firm uterine tone reduces likelihood of postpartum hemorrhage. Urinalysis positive for bacteria suggests UTI but does not explain uterine signs. Hence, lochia changes are the most direct indicator of endometritis.
Rationale for incorrect Response 1 answers:
Postpartum hemorrhage typically involves heavy bleeding, uterine atony, or a rapidly dropping hematocrit, none of which is reported here. Urinary tract infection is suggested by urinalysis but does not account for uterine tenderness or foul lochia. Deep vein thrombosis would present with limb swelling, pain, and possible fever but no uterine or lochia changes.
Rationale for incorrect Response 2 answers:
Urinalysis positive for bacteria points to UTI but not uterine infection. Elevated WBC count indicates infection or inflammation but lacks specificity for endometritis versus other infections. Uterine tone is firm here, making hemorrhage or uterine atony unlikely and less relevant to infection diagnosis.
Take home points:
- Endometritis often presents postpartum with foul-smelling lochia and elevated WBC.
- Foul-smelling lochia is a critical clinical sign distinguishing endometritis from other postpartum complications.
- Positive urinalysis suggests UTI, a separate postpartum infection that requires differentiation.
- Uterine tone helps rule out hemorrhage and guides diagnosis of infection versus atony.
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