A nurse is caring for a newborn who is 30 min old.
Jaundice
Meconium ileus*
Hypoglycemia
Meconium aspiration syndrome
The Correct Answer is D
Jaundice: Although post-term infants are at increased risk, this newborn does not yet show yellowing of the skin or sclera, which are key indicators of jaundice.
Meconium ileus: This is usually associated with cystic fibrosis and involves obstruction of the intestine by thick meconium not respiratory symptoms. This newborn's findings do not suggest GI obstruction.
Hypoglycemia: Post-term and large-for-gestational-age infants are at risk for hypoglycemia, but there are no signs like jitteriness, lethargy, or poor feeding here to support this diagnosis right now.
Meconium aspiration syndrome: This newborn was born through meconium-stained amniotic fluid and is now showing respiratory distress including rapid, shallow breathing, grunting, and fine crackles. These are hallmark signs of Meconium Aspiration Syndrome (MAS), a serious complication where the infant inhales meconium into the lungs, leading to inflammation and potential airway obstruction.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Call the provider to further assess the newborn: An apical heart rate of 130/min is within the normal range for a newborn (120-160 beats per minute). There is no need to call the provider for further assessment unless other concerning signs are present.
B. Ask another nurse to verify the heart rate: Since the heart rate of 130/min is normal for a newborn, there is no need for verification unless the nurse has a concern or there is difficulty in auscultating.
C. Document this as an expected finding: A heart rate of 130/min is considered normal for a newborn, and the nurse should document this as an expected finding without further action.
D. Prepare the newborn for transport to the NICU: A heart rate of 130/min does not indicate any immediate concerns that would require transport to the NICU. The newborn's heart rate is within normal limits.
Correct Answer is C
Explanation
A. Copious vernix: Newborns born postterm (after 42 weeks) typically have little to no vernix. Vernix, a protective coating on the skin, is generally absorbed or removed as the pregnancy progresses beyond 40 weeks. It is typically most abundant in preterm infants and decreases as the fetus approaches term. Post-term infants usually have little to no vernix.
B. Increased subcutaneous fat: While they may have initially had good subcutaneous fat stores, post-term infants can sometimes have decreased subcutaneous fat due to placental insufficiency in the later stages of pregnancy.
C. Dry, cracked skin: Postterm infants often exhibit dry, peeling, or cracked skin due to the extended exposure to amniotic fluid, which decreases as pregnancy progresses. The protective vernix caseosa has likely been absorbed, leaving the skin dry and prone to cracking. This is a common finding in infants born after 42 weeks.
D. Scant scalp hair: Postterm newborns typically have a full head of hair rather than scant hair. Scalp hair that is minimal or thin is more characteristic of preterm infants.
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