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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
A prolonged period of absent FHR variability is a critical finding that the nurse must report to the provider immediately. Absent variability indicates a significant lack of fetal well-being, potentially due to severe hypoxia, acidosis, or neurological compromise. It necessitates prompt intervention to prevent adverse outcomes.
Choice B rationale
An FHR increase to 150/min is within the normal fetal heart rate range, which typically falls between 110 and 160 beats per minute. This finding alone does not indicate a problem and would not require reporting to the provider, as it suggests adequate fetal oxygenation and an appropriately reactive fetus.
Choice C rationale
FHR accelerations of 15/min for 15 seconds are a positive sign of fetal well-being. Accelerations indicate an intact fetal nervous system and adequate oxygenation. They are a reassuring finding and suggest that the fetus is tolerating the labor process well, therefore not requiring reporting.
Choice D rationale
Early decelerations of the FHR are typically benign and do not require reporting to the provider. These decelerations are usually associated with head compression during contractions and are characterized by a gradual decrease in FHR that mirrors the contraction, indicating a physiological response.
Correct Answer is C
Explanation
Choice A rationale
Meconium aspiration syndrome is primarily associated with post-term gestation or fetal distress, where the fetus passes meconium in utero and subsequently aspirates it. While fetal distress can occur with PPROM, it is not the *most* direct or primary complication anticipated in the newborn due to preterm premature rupture of membranes itself.
Choice B rationale
Polycythemia, an abnormally high red blood cell count, is not a direct complication expected in a newborn specifically due to preterm premature rupture of membranes. It is more commonly associated with chronic hypoxia, maternal diabetes, or certain genetic conditions, and not a direct consequence of prolonged membrane rupture.
Choice C rationale
Sepsis is a significant and highly anticipated complication in a newborn following preterm premature rupture of the membranes (PPROM). The prolonged absence of the amniotic sac, which normally acts as a protective barrier, increases the risk of ascending infection from the maternal genital tract to the fetus, leading to neonatal sepsis.
Choice D rationale
Hyperbilirubinemia, or jaundice, is common in newborns, especially preterm infants, due to immature liver function. However, it is not a specific complication directly and primarily caused by preterm premature rupture of membranes. While prematurity itself is a risk factor for hyperbilirubinemia, PPROM does not directly induce elevated bilirubin levels. .
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