A pregnant woman at 37 weeks’ gestation has had ruptured membranes for 38 hours. A cesarean is performed for failure to progress. FHR baseline before birth was 180 BPM with marked variability. At birth, the newborn had Apgar scores of 6 and 7 at one and five minutes and is now noted to be pale and tachypneic. Based on the maternal history, what is the most likely cause of this newborn’s distress?
Hypoxia.
Respiratory distress syndrome.
Sepsis.
Phrenic nerve injury.
The Correct Answer is C
Choice A rationale
Hypoxia may contribute to tachypnea and distress, but it is unlikely the primary cause, as baseline fetal heart rate of 180 BPM indicates infection-related stress rather than isolated oxygen deprivation.
Choice B rationale
Respiratory distress syndrome predominantly affects preterm infants due to surfactant deficiency. At 37 weeks’ gestation, surfactant levels should be adequate, making this an unlikely cause of the newborn’s tachypnea and pallor.
Choice C rationale
Prolonged rupture of membranes increases the risk of neonatal sepsis. Signs such as tachypnea, pallor, and elevated fetal heart rate with marked variability suggest systemic infection requiring immediate evaluation and treatment.
Choice D rationale
Phrenic nerve injury typically causes diaphragmatic paralysis, leading to asymmetric chest movement and respiratory distress. However, it does not explain the systemic signs like pallor or elevated heart rate, making it an unlikely cause.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
A soft fundus indicates uterine atony, an abnormal finding requiring immediate intervention. This teaching would lead to improper patient monitoring of complications such as hemorrhage.
Choice B rationale
Clots as large as a golf ball are not considered normal and may signal uterine atony or retained placental fragments, which necessitate medical intervention for hemorrhage risk.
Choice C rationale
Decreased brownish-red lochia may reflect normal postpartum changes as it progresses to serosa and alba but is not typically an indicator of complications.
Choice D rationale
Increased lochia or a return to bright red bleeding signals potential complications like subinvolution or late postpartum hemorrhage, which demand prompt medical attention.
Correct Answer is ["A","B","C"]
Explanation
Choice A rationale
Providing family support is crucial as preterm birth can cause significant emotional distress. Education and involvement aid understanding of interventions and foster a supportive environment for both the neonate and family.
Choice B rationale
Strict handwashing and sterile technique prevent infection in preterm neonates, whose immature immune systems make them highly susceptible to sepsis, a leading cause of morbidity in NICUs.
Choice C rationale
Creating a womb-like state through dim lighting, limited noise, and careful positioning supports neurodevelopment and mimics the intrauterine environment, promoting growth and stability.
Choice D rationale
Frequent diaper changes may disturb thermoregulation and disrupt the neonate's limited energy reserves, as preterm infants require an environment that minimizes stress and conserves energy.
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