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A nurse is caring for a newborn

Exhibits
Complete the sentence below using the list of options

The newborn is at highest risk of developing  

as evidenced by the newborn’s Blank 2 

Answer and Explanation

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.


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Related Questions

Correct Answer is B

Explanation

A. An amniotic fluid index of 1 cm is abnormally low (oligohydramnios) and indicates potential fetal compromise, so this finding does not reflect fetal well-being.

B. Fetal limb movements are an important indicator of fetal activity and neurological function. Observing four or more discrete limb movements in 30 minutes meets one of the criteria for a reassuring biophysical profile, suggesting the fetus is active and neurologically intact.

C. A nonreactive nonstress test indicates the fetus is not showing adequate heart rate accelerations in response to movement, which can signal potential hypoxia or fetal compromise.

D. Sustained fetal breathing movements of 20 seconds in 30 minutes are desirable, but the minimum standard for the BPP is usually one or more episodes of 30 seconds within 30 minutes; 20 seconds alone may not meet the threshold, making limb movements a more reliable indicator in this scenario.

Correct Answer is C

Explanation

A. Effleurage is used during the first stage of labor to promote relaxation and decrease pain, not during the pushing stage, so using it while pushing is ineffective.

B. Counterpressure is most effective when applied to the lower back or sacral area during contractions, not the upper abdomen. Applying pressure to the upper abdomen would not relieve labor pain effectively.

C. Hydrotherapy involves immersing the laboring client in warm water to promote relaxation and reduce discomfort. Maintaining the water temperature between 36–37°C is safe for both mother and fetus while providing soothing pain relief.

D. A TENS unit is typically applied to the lower back during labor, not the lower abdomen, to reduce contraction-related pain. Applying it to the abdomen is not the standard practice and may not be effective.

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