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A nursery nurse is attending the birth of a post-term infant.

 

Exhibits

 

Drag words from the choices below to 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

and .
Answer and Explanation

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

Rationale for Correct Choices:

• Macrosomia: Post-term infants (≥ 42 weeks) are at higher risk of excessive birth weight due to prolonged nutrient exposure in utero. Larger infants are prone to birth trauma, shoulder dystocia, and hypoglycemia after delivery.

• Meconium aspiration syndrome: Thick green amniotic fluid indicates meconium passage in utero, likely due to fetal stress from prolonged labor and late decelerations. Inhalation of meconium-stained fluid at birth can cause airway obstruction, chemical pneumonitis, and respiratory distress.

Rationale for Incorrect Choices:

• Bronchopulmonary dysplasia: This chronic lung disease is typically a complication in premature infants requiring prolonged mechanical ventilation and high oxygen concentrations, not in post-term newborns.

• Intraventricular haemorrhage: This complication is primarily seen in premature infants with fragile germinal matrix vessels; it is uncommon in term or post-term neonates unless there is severe birth trauma or asphyxia.


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Related Questions

Correct Answer is C

Explanation

Rationale:

A. The client's lung sounds remain clear during the transfusion: Clear lung sounds indicate the absence of fluid overload or pulmonary complications, which is a safety indicator, but it does not reflect the effectiveness of the transfusion in improving oxygen-carrying capacity.

B. The client's blood pressure increases to 140/85 mm Hg following the transfusion: A sudden rise in blood pressure could indicate fluid overload or a transfusion reaction, not necessarily a positive response to the transfusion.

C. The client's hemoglobin level increases following the transfusion: An increase in hemoglobin indicates that the transfused red blood cells have effectively raised the client’s oxygen-carrying capacity, demonstrating a positive therapeutic response.

D. The client is afebrile during the transfusion: Remaining afebrile indicates the absence of a febrile transfusion reaction, which is a safety measure, but it does not show that the transfusion achieved its therapeutic goal.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"}}

Explanation

Rationale:

  • Provide the client with high-calorie fluids every hour: The client has poor self-care, has not eaten for an extended period, and exhibits hyperactivity due to mania. Frequent high-calorie fluids help maintain hydration and meet increased metabolic demands. Regular intake supports nutrition and prevents further weight loss.
  • Encourage the client to avoid napping during the day: Avoiding daytime napping can help regulate sleep-wake cycles and promote restorative sleep at night. Clients experiencing mania often have decreased need for sleep, so reinforcing nighttime sleep routines supports stabilization of circadian rhythms.
  • Minimize environmental stimuli for the client: Clients experiencing a manic episode are easily overstimulated, which can worsen their agitation, anxiety, and psychosis. A calm, quiet environment with reduced distractions is essential for de-escalation and promoting rest.
  • Weigh the client each day: Daily weight monitoring helps assess nutritional status and detect fluid imbalance, which is important given the client’s poor self-care, hyperactivity, and potential for dehydration or rapid weight loss.

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