Exhibits

Based on the Day 3 Nurses' Notes, I&O, and Diagnostic Results, which of the following findings indicate the newborn is progressing as expected? Select all that apply.

Newborn has had 4 transitional stools during the shift

Urine output remains unchanged with a dark yellow appearance

Lungs clear, no retractions noted

Edematous area on right scalp softening, ecchymosis present

Total serum bilirubin 14.2 mg/dL

Facial bruising present with yellow discoloration of the face

Answer and Explanation

Correct Answer : A,C,D

Choice A rationale: Transitional stools indicate progression from meconium to normal infant stool, reflecting adequate feeding and gastrointestinal function. These stools are typically greenish-brown to yellow and appear within the first few days of life. Four stools in one shift suggest active peristalsis and effective bilirubin excretion via feces. This is a positive sign in managing hyperbilirubinemia, as bilirubin is eliminated through the gastrointestinal tract, supporting clinical improvement.

Choice B rationale: Dark yellow urine may suggest concentrated output, potentially indicating suboptimal hydration. While unchanged output may seem stable, the color implies reduced fluid intake or increased bilirubin excretion. In neonates, urine should be pale yellow if hydration is adequate. Persistent dark urine warrants follow-up to assess feeding adequacy and renal function. It is not a definitive sign of expected progression and may signal a need for increased fluid intake.

Choice C rationale: Clear lungs and absence of retractions indicate effective respiratory function and no signs of distress. Retractions are a compensatory mechanism for increased work of breathing, often seen in respiratory compromise. Their absence, along with clear auscultation, suggests normal pulmonary transition and oxygenation. This finding confirms that the newborn is adapting well postnatally, with stable respiratory status and no need for supplemental oxygen or intervention.

Choice D rationale: Softening of the edematous scalp area and presence of ecchymosis suggest resolution of birth trauma, likely a cephalohematoma from vacuum extraction. As blood reabsorbs, firmness decreases and bruising becomes more apparent. This progression is expected and indicates healing. Monitoring is still required for bilirubin levels due to hemolysis, but the physical changes reflect normal recovery from localized trauma without signs of infection or worsening.

Choice E rationale: A total serum bilirubin level of 14.2 mg/dL remains above the normal range (1 to 12 mg/dL) and indicates ongoing hyperbilirubinemia. Although it has decreased from the previous day’s 18.5 mg/dL, it still exceeds the threshold for concern. Continued phototherapy and monitoring are necessary. This value does not yet reflect full resolution, so it cannot be considered a sign of expected progression without further decline.

Choice F rationale: Facial bruising with yellow discoloration suggests ongoing breakdown of red blood cells and bilirubin deposition in the skin. While bruising may resolve over time, the yellowing indicates persistent jaundice. This is a sign of elevated bilirubin and not a marker of improvement. It requires continued phototherapy and monitoring. Therefore, it does not indicate expected progression and warrants follow-up.

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Correct Answer is A

Explanation

Choice A rationale

Hypoglycemia in a newborn, defined as a plasma glucose level typically below 40 to 50 mg/dL, starves the central nervous system of its primary energy source, glucose. This lack of fuel in the brain cells often presents with neurological symptoms. Jitteriness (or tremors) is a classic and early neurogenic sign of this metabolic disturbance, resulting from sympathetic nervous system activation.

Choice B rationale

Hypoglycemia typically results in an attempt by the body to conserve energy and may lead to poor peripheral perfusion and decreased metabolic rate, which often manifests as hypothermia (decreased temperature). Increased temperature (hyperthermia) is not a sign of hypoglycemia; instead, it is often associated with infection or environmental overheating.

Choice C rationale

Hypoglycemia causes central nervous system instability and depression, which generally results in a decrease in a newborn's reflexes and muscle tone (hypotonia), or can lead to lethargy and poor feeding. Therefore, brisk reflexes (hyperreflexia) are not a characteristic finding and would suggest other neurological or metabolic conditions.

Choice D rationale

The Moro reflex (or startle reflex) is a complex, primitive reflex that is present and intact in healthy newborns. While severe hypoglycemia can lead to generalized central nervous system depression, which could eventually suppress all reflexes, an absence of a Moro reflex is a more specific sign of a severe neurological injury or a congenital neurological disorder, not a typical early sign of hypoglycemia.

A. Intrauterine growth restriction. B. Multiple gestation. C. Down syndrome. D. Neural tube defect.

Correct Answer is C

Explanation

Choice A rationale

Elevated maternal serum alpha-fetoprotein (MSAFP) levels are more often associated with intrauterine growth restriction (IUGR) due to placental compromise, which can lead to increased leakage of AFP into the maternal circulation. AFP is a glycoprotein produced by the fetal liver and yolk sac. Normal MSAFP levels vary by gestational week, but generally, a level ≥ 2.5 Multiples of the Median (MoM) is considered elevated.

Choice B rationale

Multiple gestation, such as twins or triplets, typically results in an elevated MSAFP because there are multiple fetuses producing AFP, leading to a higher total concentration in the maternal serum. This physiological increase requires adjustment of the median value used for interpretation to prevent false-positive results for neural tube defects.

Choice C rationale

Down syndrome (Trisomy 21) is associated with low MSAFP levels, often ≤ 0.75 MoM, along with decreased unconjugated estriol and increased human chorionic gonadotropin (hCG) and inhibin A in the quad screen. This specific pattern is due to complex, poorly understood pathophysiology related to the aneuploidy's effect on fetal protein synthesis and maternal-fetal exchange.

Choice D rationale

Neural tube defects (NTDs), such as spina bifida and anencephaly, are associated with markedly elevated MSAFP levels, usually ≥ 2.5 MoM. This is caused by the exposed fetal meninges or neural tissue leaking a large amount of AFP directly into the amniotic fluid, which then diffuses into the maternal circulation.

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Exhibits Based on the Day 3 Nurses' Notes, I&O, and Diagnostic Results, which of the following findings indicate the newborn is progressing as expected? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse collects client data and determines the newborn is most likely experiencing hypoglycemia as evidenced by which of the following?

Correct Answer is A

Explanation

A nurse is discussing a client's maternal serum alpha-fetoprotein screening results with a newly licensed nurse. Which of the following conditions is associated with low levels?

Correct Answer is C

Explanation

A nurse is assisting with the care of a client who is in labor and has received nalbuphine hydrochloride. Which of the following manifestations should the nurse identify as an adverse effect of this medication?

A nurse is collecting data from a newborn who was delivered at 40 weeks of gestation. Which of the following is an expected finding when eliciting reflexes from the newborn?

A nurse is reinforcing teaching at a prenatal visit about the importance of adequate folic acid intake with a client who is at 12 weeks of gestation. Which of the following client statements indicates an understanding of the teaching?

Exhibits A nurse is assisting in the care of a newborn. Which of the following should be included in the electronic medical record (EMR)? Select all that apply.

A nurse is reinforcing teaching with a newly licensed nurse concerning a client on a postpartum unit following a cesarean birth. Which of the following measures should the nurse include in the instructions to prevent thrombophlebitis?

A nurse is reinforcing teaching with a client who is at 18 weeks of gestation and requires an increased intake of iron. Which of the following foods should the nurse recommend as the best source of iron?

A nurse is reinforcing teaching about travel with a client who is pregnant. Which of the following instructions should the nurse include?

A nurse is planning to administer phytonadione 0.5 mg to a newborn. Available is 1 mg/0.5 mL. How many mL should the nurse administer? (Round the answer to the nearest hundredth. Use a leading zero if it applies. Do not use a trailing zero.)

Exhibits

Based on the Day 3 Nurses' Notes, I&O, and Diagnostic Results, which of the following findings indicate the newborn is progressing as expected? Select all that apply.