A nurse is caring for a newborn who is 30 minutes old in the newborn nursery.
The condition that poses the greatest risk to the newborn is
The Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"B"}
The condition that poses the greatest risk to the newborn is meconium aspiration syndrome due to amniotic fluid.
Rationale for correct answers
Meconium aspiration syndrome (MAS) occurs when a newborn inhales meconium-stained amniotic fluid, leading to airway obstruction, chemical pneumonitis, and surfactant dysfunction. The presence of dark brown-greenish amniotic fluid, along with mild respiratory distress (nasal flaring, increased respiratory rate of 60/min), raises concern for MAS. Close monitoring for worsening respiratory symptoms is essential.
Amniotic fluid contamination with meconium increases the risk of lung inflammation and infection. The newborn’s vigorous condition suggests mild aspiration, but continuous observation is needed.
Rationale for incorrect Response 1 options
- Jaundice: While term newborns may develop physiological jaundice, there are no indications of hyperbilirubinemia or hemolysis in this case.
- Hypoglycemia: No jitteriness or poor feeding, and birth weight is within normal range; hypoglycemia more commonly affects preterm or low birth weight infants.
- Cold stress: The newborn is under a radiant warmer, and temperature is within normal range (36.5°C).
Rationale for incorrect Response 2 options
- Birth weight: No signs of growth restriction or macrosomia-associated complications.
- Acrocyanosis: Normal in newborns due to immature circulation, not an indicator of respiratory compromise.
- Apgar scores: Strong Apgar scores (8 and 9) suggest good adaptation to extrauterine life.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Limiting the newborn's intake of milk is contraindicated in the treatment of hyperbilirubinemia. Adequate hydration and frequent feedings are essential to promote bilirubin excretion through stool and urine. Decreased intake can exacerbate dehydration and worsen jaundice. Normal feeding frequency for newborns is typically every 2-3 hours.
Choice B rationale
Feeding the newborn every six hours is not an appropriate intervention for a jaundiced infant receiving phototherapy. Frequent feedings, typically every 2-3 hours, are necessary to promote bilirubin excretion. Prolonged intervals between feedings can lead to dehydration and hinder the effectiveness of phototherapy.
Choice C rationale
Turning the infant every two hours is a crucial nursing intervention during phototherapy. This ensures that all body surfaces are exposed to the ultraviolet light, maximizing the breakdown of bilirubin in the skin. Consistent exposure of all areas helps to lower bilirubin levels more effectively.
Choice D rationale
Applying an oil-based lotion to the newborn's skin during phototherapy is contraindicated. Oil-based lotions can create a barrier on the skin, reducing the penetration and effectiveness of the ultraviolet light. Only water-based lotions, if necessary, should be used sparingly and with caution, as some may absorb UV light.
Correct Answer is C
Explanation
Choice A rationale
Oral contraceptives primarily work by inhibiting ovulation through hormonal regulation. They do not inherently increase the risk of pelvic inflammatory disease (PID). In some cases, they may even offer a protective effect against PID by thickening cervical mucus, which can act as a barrier to ascending infections.
Choice B rationale
Frequent alcohol use can impair the immune system, potentially making an individual more susceptible to infections. However, it is not a direct cause of PID. PID is primarily caused by ascending infections, often sexually transmitted infections, rather than the direct effects of alcohol consumption.
Choice C rationale
Chlamydia trachomatis is a common sexually transmitted bacterium and a major cause of pelvic inflammatory disease. Untreated chlamydia infections can ascend from the cervix and uterus to the fallopian tubes and ovaries, leading to inflammation, scarring, and potentially long-term complications such as infertility and ectopic pregnancy.
Choice D rationale
Recurrent cystitis, an infection of the bladder, primarily affects the lower urinary tract. While urinary tract infections are common in women, they do not typically ascend to the reproductive organs and cause pelvic inflammatory disease. PID involves infection of the upper genital tract, including the uterus, fallopian tubes, and ovaries.
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