A nurse is caring for a newborn
The newborn is at highest risk of developing
The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}
- Hyperbilirubinemia is a concern due to the presence of cephalohematoma (a firm, edematous area on the scalp that does not cross suture lines) and yellow sclera, both of which are indicators of increased bilirubin from red blood cell breakdown.
- The head assessment reveals these findings (scleral icterus and cephalohematoma), which directly support the risk.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Irrigating the insertion site with sterile water is not a standard part of the procedure.
B. Rh-negative clients are at risk for isoimmunization if fetal blood mixes with maternal blood during the procedure. Rh(D) immune globulin should be administered after the procedure to prevent Rh sensitization.
C. The client is usually positioned supine with a slight tilt to prevent vena cava compression, not strictly in a left lateral position.
D. Amniocentesis does not require the client to be NPO.
Correct Answer is ["A","B"]
Explanation
- Oral temperature 38.3°C (101°F)
Elevated temperature indicates maternal fever, which could suggest infection such as chorioamnionitis, especially concerning with ruptured membranes. - HGB 10 g/dL (normal > 11 g/dL)
Low hemoglobin indicates anemia, which could compromise oxygen delivery to the fetus and affect maternal health during labor.
Explanation for non-highlighted findings:
- Heart rate 98/min: Slightly elevated but within normal range for labor.
- Blood pressure 112/59 mm Hg: Normal blood pressure for pregnancy.
- Uterine contractions every 3 mins moderate to palpation: Normal pattern for active labor.
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