A nursery nurse is attending the birth of a post-term infant
Fill in each blank in the following sentence.
Upon review of the medical record, the nurse should determine the infant newborn is at risk for developing
The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C"}
Rationale for correct choices:
- Macrosomia: Post-term infants (≥42 weeks gestation) have prolonged exposure to intrauterine nutrients, increasing the risk of excessive fetal growth. Macrosomia is common and can lead to complications such as shoulder dystocia or birth trauma.
- Meconium aspiration syndrome: As gestation progresses beyond term, placental function may decline, increasing fetal stress. This can trigger passage of meconium in utero and aspiration during delivery, especially with late decelerations suggesting uteroplacental insufficiency.
Rationale for incorrect choices:
- Intraventricular hemorrhage: This condition is typically associated with preterm infants due to fragile cerebral vasculature. A post-term newborn is not at increased risk for IVH.
- Bronchopulmonary dysplasia: BPD is a chronic lung disease most often seen in premature infants requiring prolonged mechanical ventilation and oxygen therapy. It is not a common concern for post-term infants.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","E","F"]
Explanation
Rationale:
A. Blood pressure: The reading of 162/112 mm Hg meets the criteria for severe hypertension in pregnancy, which increases the risk of complications such as preeclampsia, placental abruption, and stroke.
B. Urine ketones: Ketones are negative, which rules out dehydration or starvation ketosis. Ketones would be more concerning if elevated alongside hyperemesis or gestational diabetes.
C. Fetal activity: Decreased fetal movement at 31 weeks may indicate fetal hypoxia or distress and requires urgent evaluation with nonstress testing or biophysical profiling.
D. Respiratory rate: The client’s respiratory rate of 16/min is within the normal range (12–20/min) and does not indicate respiratory distress or a complication.
E. Report of headache: A severe, persistent headache that is unrelieved by acetaminophen is a classic warning sign of central nervous system involvement in preeclampsia and may precede seizures (eclampsia).
F. Urine protein: The presence of 3+ proteinuria indicates significant renal involvement, supporting a diagnosis of preeclampsia, particularly when paired with hypertension and neurologic symptoms.
G. Gravida/parity: While a history of preterm birth is a known risk factor, her current symptoms point toward preeclampsia rather than complications directly linked to her obstetric history.
Correct Answer is B
Explanation
Rationale:
A. Administer the medication as prescribed: Administering amoxicillin to a client with a penicillin allergy can result in serious allergic reactions, including rash, hives, or anaphylaxis. Amoxicillin is a penicillin derivative, it is contraindicated in patients with penicillin allergies.
B. Discuss the prescription with the health care provider: The nurse must clarify potentially harmful prescriptions directly with the provider. This ensures patient safety by verifying if the medication should be changed, considering the client’s documented allergy to penicillin.
C. Call the pharmacist for clarification of the medication contraindications: While pharmacists can verify drug classes and potential reactions, they do not have the authority to discontinue or modify a prescription. Only the healthcare provider can make necessary changes to an order.
D. Place an incident report in the medical record: Incident reports are meant for internal documentation and are never placed in the client’s medical record. Since the error has not occurred yet, prevention through provider consultation is the priority action.
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