A nurse is caring for a newborn
Which findings are risk factors for the newborn to develop a complication? Select all that apply
Maternal Rh factor
Gestational age
Apgar scores
Weight
Type of birth
Length
Correct Answer : B,E
A. Maternal Rh factor – The mother is O positive. Rh incompatibility is not a concern here because both mother and newborn are likely Rh positive, and no information suggests Rh incompatibility.
B. Gestational age – The newborn was born at 36 weeks and 4 days, which is considered late preterm and places the infant at increased risk for complications such as respiratory distress, jaundice, hypoglycemia, and feeding difficulties.
C. Apgar scores – Scores of 7 at 1 minute and 8 at 5 minutes are within the normal range and not indicative of distress or a complication risk.
D. Weight – A birth weight of 3,062 g (6 lb 12 oz) is appropriate for gestational age and not a risk factor.
E. Type of birth – Operative vaginal birth using a vacuum extractor increases the risk for complications like cephalohematoma, which is noted in the assessment (firm, edematous scalp area with ecchymosis not crossing suture lines). This can contribute to jaundice.
F. Length – A length of 48 cm (19 in) is appropriate for gestational age and not a risk factor.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D"]
Explanation
A. Abdominal assessment – The abdomen is tender to palpation, which is an abnormal finding and can indicate uterine activity or irritation associated with preterm labor or other complications.
B. Low back pain – This is a common early sign of preterm labor, especially when combined with uterine cramping and cervical changes.
C. Uterine contractions – Although the client has cramping, there is no specific documentation of palpable or monitor-confirmed contractions, so this cannot be definitively selected based on available data.
D. Abdominal cramping – This is concerning in a pregnant client at 30 weeks, especially in combination with cervical dilation, vaginal bleeding, and back pain.
E. Fundal height – At 30 weeks, a fundal height of 28 cm is within the normal range (should match gestational age ±2 cm). This is not abnormal.
F. Fetal heart rate – The scenario notes positive fetal movement but does not mention an abnormal FHR. Without abnormal FHR data, this cannot be selected.
Correct Answer is A
Explanation
A. The diaphragm should be inserted after emptying the bladder to reduce the risk of urinary tract infections.
B. Baby powder should not be applied to the diaphragm as it can cause irritation or damage.
C. Oil-based lubricants can degrade latex diaphragms and reduce their effectiveness; only water-based lubricants should be used.
D. The diaphragm should be left in place for at least 6 hours after intercourse, not just 4 hours, to ensure effective contraception.
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