A nurse is caring for a newborn who is 30 min old.

Exhibits

Drag 1 condition and 1 client finding to fill in each blank in the following sentence.

After reviewing the information in the newborn's medical record, which of the following complications should the nurse identify as posing the greatest risk?

The condition that poses the greatest risk to the newborn is
_
due to
_
.

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}

Meconium aspiration syndrome (MAS) occurs when a newborn inhales meconium-stained amniotic fluid during or after delivery, leading to respiratory distress. This newborn has several findings consistent with MAS:

Dark brown-greenish amniotic fluid during labor indicates meconium-stained fluid.

Fine crackles throughout lung fields and expiratory grunting suggest impaired gas exchange and possible airway obstruction.

Rapid and shallow respirations (80/min) and the presence of green-stained vernix and fingernails further support this diagnosis.

Jaundice, hypoglycemia, and cold stress are also potential complications in newborns but are not the most immediate threats based on this newborn's clinical presentation.

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Correct Answer is D

Explanation

A. Heart Rate: 108 bpm = 2 points, Respiratory Effort: Regular rate with a cry = 2 points, Muscle Tone: Some flexion = 1 point, Reflex Irritability: Vigorous cry with stimulation = 2 points, Color: Pink body, blue extremities (acrocyanosis) = 1 point: Total APGAR Score: 8
B. A. Heart Rate: 108 bpm = 2 points, Respiratory Effort: Regular rate with a cry = 2 points, Muscle Tone: Some flexion = 1 point, Reflex Irritability: Vigorous cry with stimulation = 2 points, Color: Pink body, blue extremities (acrocyanosis) = 1 point: Total APGAR Score: 8
C. A. Heart Rate: 108 bpm = 2 points, Respiratory Effort: Regular rate with a cry = 2 points, Muscle Tone: Some flexion = 1 point, Reflex Irritability: Vigorous cry with stimulation = 2 points, Color: Pink body, blue extremities (acrocyanosis) = 1 point: Total APGAR Score: 8
D. A. Heart Rate: 108 bpm = 2 points, Respiratory Effort: Regular rate with a cry = 2 points, Muscle Tone: Some flexion = 1 point, Reflex Irritability: Vigorous cry with stimulation = 2 points, Color: Pink body, blue extremities (acrocyanosis) = 1 point: Total APGAR Score: 8

A. Dry the neonate immediately. B. Perform APGAR screening every 30 minutes until scores are 27. C. Complete neonatal assessment prior to allowing the baby to feed. D. Obtain blood sample to test for blood type.

Correct Answer is A

Explanation

A. The nurse should dry the neonate immediately after birth to prevent heat loss, as newborns are at risk for hypothermia.
B. APGAR scoring is typically done 1 and 5 minutes after birth, not every 30 minutes during the 3rd stage of labor.
C. The neonatal assessment is usually performed after the delivery of the placenta, not during the 3rd stage of labor.
D. Blood samples for blood type are typically obtained after the newborn has stabilized, not during the 3rd stage of labor.

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Naxlex Comprehensive Predictor Exams

The nurse notes that a newborn, who is 5 minutes old, exhibits the following characteristics: pink body with blue hands and feet, heart rate 108 bpm. respiratory rate 36 per minute, some flexion, and a vigorous cry with stimulation. What does the nurse determine the baby's APGAR score to be?

Correct Answer is D

Explanation

The nurse is providing care for a neonate during the 3rd stage of labor. Which action does the nurse take during this stage?

Correct Answer is A

Explanation

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