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 {"dropdown-group-1":"A","dropdown-group-2":"A"}
Explanation
The nurse should anticipate a provider prescription for pyridoxine due to the client’s severe dehydration.
Rationale for correct answers
Pyridoxine (vitamin B6) is recommended for nausea and vomiting in pregnancy (NVP), commonly known as hyperemesis gravidarum (HG), especially in patients with persistent symptoms leading to dehydration. Severe dehydration is confirmed by elevated urine specific gravity (normal: 1.002–1.030), low sodium (normal: 135–145 mEq/L), and positive ketones, indicating excessive vomiting and malnutrition.
Rationale for incorrect Response 1 options
- Antibiotics: There is no evidence of infection; urinalysis and WBC count are within normal limits.
- Magnesium sulfate: Used for eclampsia or preterm labor prevention, not for HG.
- Oxytocin: Stimulates uterine contractions and is contraindicated during early pregnancy unless labor induction is required.
Rationale for incorrect Response 2 options
- Urinary tract infection: No leukocytes or nitrites in urine, and WBC count is normal (4,500–11,000/mm³).
- Preeclampsia: No proteinuria or hypertension (≥140/90 mm Hg).
- Preterm labor: No uterine contractions or cervical changes.
Correct Answer is D
Explanation
Choice A rationale
Rapid plasma regain is not a standard laboratory test associated with hyperemesis gravidarum. Hyperemesis gravidarum involves significant fluid and electrolyte losses, but rapid plasma regain is not a specific indicator of this condition.
Choice B rationale
A urine culture is used to detect the presence of bacteria in the urine, typically to diagnose a urinary tract infection. While dehydration from hyperemesis gravidarum can increase the risk of a UTI, a urine culture is not a primary anticipated laboratory test for hyperemesis itself.
Choice C rationale
Prothrombin time (PT) is a blood test that measures how long it takes blood to clot. It is used to assess coagulation and is not directly related to the metabolic and electrolyte imbalances caused by hyperemesis gravidarum.
Choice D rationale
Urine ketones are a byproduct of fat breakdown for energy, which occurs when the body is not getting enough glucose. In hyperemesis gravidarum, persistent vomiting can lead to dehydration and starvation, forcing the body to break down fat for energy, resulting in ketonuria (ketones in the urine).
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