The nurse identifies that which infant is at the highest risk of infection?
38-week infant born via cesarean section for breech presentation.
36-week infant, small for gestational age.
41-week infant born to a GDM mother.
38-week infant born with caput succedaneum.
The Correct Answer is B
Choice A rationale
A cesarean delivery may increase infection risk due to surgical exposure, but a full-term infant born at 38 weeks has more mature immune defenses compared to preterm or growth-restricted infants.
Choice B rationale
A 36-week infant, small for gestational age, has underdeveloped immune function and possible intrauterine growth restriction, which increases susceptibility to infections. Immaturity in skin and mucosal barriers heightens the risk.
Choice C rationale
Infants born to mothers with gestational diabetes may experience metabolic complications, but infection risk is lower in full-term infants due to relatively mature immune function and adequate birth weight.
Choice D rationale
Caput succedaneum may present a localized risk of infection, but a 38-week infant has a more mature immune system compared to premature or growth-restricted infants, thus reducing overall susceptibility to infections.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Urine output of 40 mL in 8 hours indicates oliguria, suggesting inadequate renal perfusion. Normal urine output is 30 mL/hour or greater. This could signify hypovolemia or renal compromise post-hemorrhage.
Choice B rationale
A drop in hematocrit of 2% may be expected postpartum and is not immediately concerning unless accompanied by hemodynamic instability or symptoms of anemia like dizziness or fatigue.
Choice C rationale
A 2 lb weight decrease postpartum is normal due to fluid shifts and diuresis. It does not indicate an emergent condition requiring immediate reporting to the obstetrician.
Choice D rationale
A pulse rate of 68 beats per minute is within the normal adult range of 60 to 100 beats per minute and is not typically concerning post-delivery.
Correct Answer is A
Explanation
Choice A rationale
Visual impairment, including retinopathy of prematurity, results from immature retinal vascularization and oxidative damage caused by prolonged oxygen therapy in premature infants, leading to neovascularization and potential retinal detachment.
Choice B rationale
Sensitivity to touch reflects neurologic immaturity or overstimulation in premature infants but is not directly associated with oxygen therapy. It stems from underdeveloped sensory pathways and an immature central nervous system.
Choice C rationale
Hyperbilirubinemia arises from excessive bilirubin production or impaired hepatic clearance in neonates, unrelated to oxygen therapy. Factors include hemolysis, immature liver enzyme systems, or delayed feeding initiation.
Choice D rationale
Cerebral palsy, a motor disorder due to non-progressive brain injury, can result from perinatal asphyxia or intracranial hemorrhage, but it is not a direct outcome of oxygen therapy in premature infants.
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