The most important reason to protect the preterm infant from cold stress is that:

It could make respiratory distress syndrome worse.

Shivering to produce heat may use up too many calories.

A low temperature may make the infant less able to digest nutrients.

Cold decreases circulation to the extremities.

Answer and Explanation

The Correct Answer is A

A) It could make respiratory distress syndrome worse:
The most critical reason to protect a preterm infant from cold stress is that hypothermia can exacerbate respiratory distress syndrome (RDS). Cold stress leads to an increased oxygen demand, which can worsen the infant’s already compromised respiratory function. In preterm infants, the immature lungs and underdeveloped surfactant production contribute to RDS, and hypothermia worsens the situation by increasing metabolic demands and impairing pulmonary function. Maintaining a stable body temperature is crucial for minimizing respiratory complications.

B) Shivering to produce heat may use up too many calories:
While it is true that preterm infants may not have the metabolic reserves to generate heat via shivering (as they lack significant brown fat), the primary concern is not shivering. Preterm infants generally do not shiver, and cold stress does not trigger this response. Instead, their body tries to conserve heat through vasoconstriction and increased metabolism, which can lead to hypoxia and worsening respiratory distress.

C) A low temperature may make the infant less able to digest nutrients:
Cold stress can affect a preterm infant’s gastrointestinal function by reducing blood flow to the digestive organs, which can impair nutrient absorption and digestion. However, the most immediate and serious consequence of cold stress is the increased metabolic demand and worsening of respiratory distress, rather than a direct impact on digestion. Protecting the infant from hypothermia helps prevent these secondary complications.

D) Cold decreases circulation to the extremities:
While cold stress can indeed lead to vasoconstriction and decreased circulation to the extremities, this is not the most significant concern. The primary issue with cold stress in preterm infants is the overall increase in metabolic demands, oxygen consumption, and exacerbation of respiratory problems, which can lead to more severe respiratory distress syndrome. The loss of peripheral circulation is a secondary concern.

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Correct Answer is A

Explanation

A. Excessive uterine bleeding:
Bladder distention can displace the uterus to the right and elevate it above the umbilicus, interfering with uterine contraction. This displacement prevents the uterus from contracting effectively, which can lead to excessive uterine bleeding, a serious complication. When the uterus does not contract properly, it may not effectively compress the blood vessels, increasing the risk of hemorrhage. Immediate attention to bladder distention is crucial to prevent this potentially life-threatening issue.

B. Urinary tract infection:
While urinary tract infections (UTIs) can occur in the postpartum period, especially if the bladder is not emptied completely, they are not the most immediate or serious consequence of bladder distention. The priority is to address the distended bladder to prevent complications like excessive bleeding. A UTI would be a concern later, but it would not be the most acute risk following delivery.

C. Ruptured bladder:
A ruptured bladder is a rare and severe complication but is not the most likely consequence of bladder distention in the immediate postpartum period. Bladder rupture typically occurs due to significant trauma or extreme distention, which is not common in this situation. The more immediate concern is uterine atony and hemorrhage due to displaced uterine tone from bladder distention.

D. Bladder wall atony:
Bladder wall atony could result from severe bladder distention, causing difficulty in voiding. However, this is not the most serious consequence immediately after birth. Bladder distention typically results in impaired uterine contraction, which causes bleeding rather than atony of the bladder wall itself. Addressing bladder distention will help prevent complications such as hemorrhage rather than focusing on bladder atony initially.

A. First baby, day of delivery, fundus 2 cm above umbilicus deviated to left. B. Second baby, first postpartum day, hypoactive bowel sounds all quadrants. C. Third baby, first postpartum day, 3 cm diastasis recti abdominis D. Second baby, third day post-cesarean, moderate lochia serosa.

Correct Answer is A

Explanation

A) First baby, day of delivery, fundus 2 cm above umbilicus deviated to left:
This is the most urgent situation. The fundus should typically be at the level of the umbilicus on the first postpartum day. A fundus that is 2 cm above the umbilicus and deviated to the left may indicate that the bladder is full, which can cause uterine displacement. This is a priority because if the bladder is not emptied, it could lead to uterine atony or hemorrhage. The nurse should first assess the bladder and encourage the client to void, or catheterize if needed, to correct the deviation.

B) Second baby, first postpartum day, hypoactive bowel sounds all quadrants:
Hypoactive bowel sounds on the first postpartum day can be expected, particularly after a cesarean section or due to the effects of medications such as opioids. While this finding should be monitored, it is not as urgent as a potential issue with uterine positioning that could affect bleeding or uterine tone.

C) Third baby, first postpartum day, 3 cm diastasis recti abdominis:
Diastasis recti abdominis, where the abdominal muscles separate, is a common finding postpartum, especially after multiple pregnancies. While it may cause discomfort, it is generally not an immediate concern unless there is significant pain or other complications. It can be addressed with physical therapy over time.

D) Second baby, third day post-cesarean, moderate lochia serosa:
Lochia serosa is the expected discharge 3 days postpartum after a cesarean. Moderate lochia serosa is normal at this stage and does not indicate an immediate problem. The nurse should continue to monitor the lochia, but this is not as urgent as addressing the possible uterine displacement and bladder issue in Option A.

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