A nurse is caring for a newborn in the labor and delivery unit.
A nurse on the labor and delivery unit is assisting in the care of a newborn at 1 hr old.
Click to highlight the findings that require follow-up. To deselect a finding, click on the finding again.
APGAR score of 7 at 1 minute and 9 at 5 minutes
Birth weight of 4,224 g (9 lb 5 oz)
Acrocyanosis present
Difficulty latching during initial breastfeeding
Jitteriness with abnormal crying
Temperature 36.3° C (97.3° F) with mild hypotonia
Correct Answer : B,D,E,F
Choice A rationale: An Apgar score of 7 at 1 minute and 9 at 5 minutes reflects appropriate neonatal transition. The Apgar scale assesses heart rate, respiratory effort, muscle tone, reflex irritability, and color. A score of 7–10 is considered normal. Improvement from 7 to 9 indicates effective adaptation to extrauterine life. No follow-up is required unless scores remain below 7 or decline, which could suggest perinatal compromise or need for resuscitation.
Choice B rationale: A birth weight of 4,224 g (9 lb 5 oz) classifies the newborn as large for gestational age (LGA), which increases the risk for neonatal hypoglycemia. LGA infants often experience hyperinsulinemia due to maternal diabetes or excessive glucose exposure in utero. After birth, insulin levels remain high while glucose supply drops, leading to hypoglycemia. This metabolic imbalance requires close monitoring of glucose levels and feeding adequacy to prevent neurologic sequelae.
Choice C rationale: Acrocyanosis is a benign finding in the first 24–48 hours of life due to immature peripheral circulation. It presents as bluish discoloration of the hands and feet while central perfusion remains intact. It does not indicate hypoxemia or cardiovascular compromise. The condition resolves spontaneously as peripheral vasomotor tone matures. No follow-up is needed unless central cyanosis or respiratory distress develops, which would suggest a more serious pathology.
Choice D rationale: Difficulty latching during initial breastfeeding can lead to inadequate caloric intake and increase the risk of hypoglycemia, especially in LGA infants. Effective latching is essential for milk transfer and glucose stabilization. Poor latch may result from anatomical issues, maternal technique, or infant fatigue. Early intervention with lactation support is critical to ensure feeding success and prevent metabolic instability. This finding warrants follow-up to optimize nutrition and glucose regulation.
Choice E rationale: Jitteriness with abnormal crying is a clinical sign of neonatal hypoglycemia. Hypoglycemia affects neuronal excitability, leading to tremors, irritability, and altered cry patterns. Blood glucose levels below 40–45 mg/dL impair cerebral function and may cause seizures if untreated. Jitteriness must be differentiated from normal newborn tremors, and glucose levels should be promptly assessed. This symptom requires immediate follow-up to prevent neurologic injury and ensure metabolic stability.
Choice F rationale: A temperature of 36.3° C (97.3° F) with mild hypotonia suggests hypothermia and possible hypoglycemia. Neonates have limited thermoregulatory capacity and rely on brown fat metabolism, which consumes glucose. Hypothermia increases glucose utilization, exacerbating hypoglycemia risk. Mild hypotonia reflects reduced neuromuscular tone, a sign of central nervous system depression. These findings require follow-up to stabilize temperature and glucose levels, preventing further metabolic compromise.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Normal vaginal fluid is acidic due to the presence of Lactobacillus species, which convert glycogen to lactic acid, maintaining a pH typically between 4.5 and 6.0. Amniotic fluid is alkaline, with a pH usually ranging from 7.0 to 7.5. Therefore, a pH of 5.3 indicates acidic vaginal secretions, suggesting the fluid is likely not amniotic fluid and ruling out premature rupture of membranes (PROM).
Choice B rationale
Nitrazine paper is used to test the pH of vaginal fluid. It is impregnated with a pH-sensitive dye. When the paper comes into contact with acidic fluid (normal vaginal secretions, pH < 6.0), it will remain yellow or turn a yellow-green color. This result indicates an acidic environment, which is inconsistent with the alkaline nature of amniotic fluid (pH≥ 6.5), making PROM unlikely.
Choice C rationale
Ferning refers to the characteristic microscopic crystallization pattern that dried amniotic fluid forms due to its salt and protein content. A negative ferning test means the characteristic pattern is absent. This negative result suggests the fluid is not amniotic fluid, thereby providing evidence against the diagnosis of premature rupture of membranes (PROM).
Choice D rationale
Nitrazine paper turning a dark blue color (or royal blue, deep blue-green, or deep blue) indicates an alkaline pH of 6.5 or greater. Amniotic fluid is alkaline, typically with a pH of 7.0 to 7.5. Therefore, this color change strongly suggests the presence of amniotic fluid, which is the defining diagnostic finding for premature rupture of membranes (PROM).
Correct Answer is ["A","B","C","D","G"]
Explanation
Choice A rationale: Skin-to-skin contact promotes thermoregulation, stabilizes heart rate and respiratory rate, and enhances glucose homeostasis through reduced stress hormone release. It also facilitates breastfeeding by stimulating maternal oxytocin and infant rooting reflexes. In hypoglycemic newborns, skin-to-skin reduces energy expenditure and supports metabolic recovery. This intervention is evidence-based and essential for physiologic stabilization and bonding, especially in infants with feeding difficulties or temperature instability.
Choice B rationale: Rechecking glucose levels is critical to confirm sustained euglycemia and detect rebound hypoglycemia. Neonatal glucose regulation is dynamic, especially in large-for-gestational-age infants. After initial correction, glucose may drop again due to persistent hyperinsulinemia. Monitoring ensures timely intervention and prevents neurologic sequelae. The normal range for neonatal blood glucose is greater than 40 to 45 mg/dL. Serial checks guide feeding frequency and determine need for escalation of care.
Choice C rationale: Temperature monitoring is essential because hypothermia increases glucose utilization and exacerbates hypoglycemia. Newborns have immature thermoregulatory mechanisms and rely on external warmth and brown fat metabolism. A stable temperature of 36.5° C (97.7° F) is ideal. Rechecking ensures that swaddling and skin-to-skin are effective and that no environmental factors are compromising thermal stability. Temperature instability may signal underlying metabolic or infectious processes requiring further evaluation.
Choice D rationale: Reinforcing hourly breastfeeding supports frequent glucose intake and prevents hypoglycemia recurrence. Early and regular feeding is the cornerstone of neonatal glucose management. Hourly feeding ensures adequate caloric delivery, stimulates gastrointestinal motility, and promotes bilirubin excretion. It also helps establish maternal milk supply and improves latch technique through repetition. This action is especially important in infants with initial feeding difficulties or borderline glucose levels.
Choice E rationale: Tightly swaddling provides warmth and comfort but is not a primary intervention once temperature is stable. While swaddling supports thermoregulation and reduces energy expenditure, it does not directly address glucose regulation or feeding. In this case, the newborn’s temperature has normalized, and swaddling has already been implemented. Therefore, it is not a next-step priority but rather a maintenance measure.
Choice F rationale: Maintaining an IV catheter is unnecessary unless glucose levels remain critically low or feeding fails. The newborn’s glucose improved to 50 mg/dL after breastfeeding, indicating effective oral management. IV glucose is reserved for symptomatic hypoglycemia or levels below 25 mg/dL. In this stable scenario, invasive therapy is not warranted and may introduce infection risk or parental anxiety. Thus, it is not an appropriate next action.
Choice G rationale: Scheduling a lactation consult addresses the initial difficulty with latching and supports long-term feeding success. Lactation specialists provide hands-on guidance, assess anatomical barriers, and educate on positioning and milk transfer. Early intervention improves breastfeeding outcomes and reduces risk of hypoglycemia, dehydration, and jaundice. This consult is especially important for large infants with high metabolic demands and mothers needing support.
Choice H rationale: Monitoring for dehydration is important but not immediately indicated unless signs such as poor skin turgor, dry mucosa, or decreased urine output appear. The newborn has breastfed and is sleeping quietly, suggesting adequate hydration. While vigilance is necessary, it is not a top-five priority at this moment. Dehydration monitoring becomes more relevant if feeding remains poor or output declines.
Choice I rationale: Supplemental oxygen is not indicated in a newborn with normal respiratory rate, heart rate, and oxygen saturation. The newborn is alert, crying, and has no retractions or cyanosis. Oxygen therapy is reserved for hypoxemia or respiratory distress. Unnecessary oxygen can suppress respiratory drive and interfere with thermoregulation. Therefore, it is not appropriate in this stable clinical context.
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