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 B
Explanation
Choice A rationale
Elastic stockings help improve venous return, reducing clot propagation in thrombophlebitis. Proper usage minimizes symptoms like pain and swelling, and supports overall vein health, crucial for recovery and preventing complications.
Choice B rationale
Massaging an affected leg with thrombophlebitis is contraindicated as it increases the risk of clot dislodgement, potentially leading to a life-threatening pulmonary embolism. This misconception highlights the need for further client education.
Choice C rationale
Avoiding prolonged sitting prevents venous stasis and encourages circulation, which is vital in thrombophlebitis management to prevent worsening of clotting and associated complications such as pain or swelling.
Choice D rationale
Elevating the affected leg reduces swelling and promotes venous drainage, alleviating discomfort associated with thrombophlebitis. This intervention supports the resolution of inflammation in the superficial veins.
Correct Answer is D
Explanation
Choice A rationale
A soft uterus indicates uterine atony, a complication rather than a normal finding. Daily fundal palpation ensures involution but should result in a firm, not soft, uterus.
Choice B rationale
Passage of clots is common postpartum, but ongoing monitoring for excessive clotting is crucial as it may indicate retained placental fragments or incomplete uterine involution.
Choice C rationale
Decreased lochia does not indicate complications unless it is completely absent, which may suggest uterine or cervical obstruction and warrants further evaluation.
Choice D rationale
Increased lochia or bright red bleeding signifies secondary postpartum hemorrhage, often caused by retained placental tissue or subinvolution, requiring immediate medical attention.
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