Which assessment finding in a newborn places them at risk for physiological jaundice?

Acrocyanosis.

Mongolian spots.

Cephalohematoma.

Caput succedaneum.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Acrocyanosis, or bluish discoloration of extremities, is a normal newborn finding reflecting immature circulation and does not pose a risk for jaundice. It resolves as circulatory function matures and is unrelated to bilirubin metabolism or hemolysis.

Choice B rationale

Mongolian spots are benign pigmented birthmarks caused by trapped melanocytes in the dermis. These spots have no connection to jaundice and do not reflect bilirubin accumulation or red blood cell breakdown.

Choice C rationale

Cephalohematoma results from birth trauma, causing localized blood collection between the skull and periosteum. The breakdown of pooled blood increases bilirubin production, raising jaundice risk. This complication reflects excessive hemolysis, leading to bilirubin elevation.

Choice D rationale

Caput succedaneum involves superficial scalp swelling due to delivery pressure. Unlike cephalohematoma, it does not contribute to hemolysis or bilirubin accumulation. It resolves spontaneously and poses no risk for jaundice development.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A rationale

Determining the time of the last pad change assesses the rate of bleeding, which is crucial for evaluating postpartum hemorrhage. Bright red blood saturation indicates active bleeding, requiring quantification. If pads are saturated within an hour, immediate intervention is needed to prevent hypovolemic shock.

Choice B rationale

Asking about clots identifies uterine atony or retained placental fragments. However, it does not prioritize the bleeding rate assessment, which is critical for immediate hemodynamic stability and guides urgency in management.

Choice C rationale

Cramping indicates uterine contractions aiding involution. While helpful for understanding uterine activity, it does not directly evaluate the severity or rate of blood loss, which poses an immediate risk to the client’s life.

Choice D rationale

Checking for the need to urinate helps assess bladder distension. A full bladder inhibits uterine contraction, worsening atony-related bleeding. Still, this line of questioning is less critical compared to assessing the bleeding's rate and volume.

A. The client's blood contains the Rh factor and the newborn's does not, and antibodies that destroy red blood cells are formed in the fetus. B. The client's anti-A and anti-B antibodies cross the placenta and cause the destruction of the fetal red blood cells. C. The client has a history of receiving a transfusion with Rh-negative blood. D. The client's blood does not contain the Rh factor, so she produces anti-Rh antibodies that cross the placental barrier and cause hemolysis of red blood cells in newborns.

Correct Answer is D

Explanation

Choice A rationale

The presence of Rh factor in the mother's blood and absence in the newborn’s does not lead to antibody formation targeting fetal red blood cells directly. Rh incompatibility arises when the mother lacks the Rh factor and forms anti-Rh antibodies against the Rh-positive fetal blood. This leads to hemolysis and hyperbilirubinemia in affected newborns.

Choice B rationale

Anti-A and anti-B antibodies are associated with ABO incompatibility, not Rh incompatibility. ABO incompatibility can cause mild hemolysis but does not lead to severe hyperbilirubinemia seen in Rh incompatibility. Rh incompatibility specifically involves anti-Rh antibodies produced by Rh-negative mothers targeting Rh-positive fetal red cells.

Choice C rationale

Receiving a transfusion with Rh-negative blood would not trigger Rh incompatibility. Rh incompatibility is driven by maternal sensitization to Rh-positive fetal blood during pregnancy or delivery, leading to antibody formation and subsequent hemolysis in future Rh-positive pregnancies.

Choice D rationale

When the mother lacks the Rh factor (Rh-negative), she can produce anti-Rh antibodies upon exposure to Rh-positive fetal blood. These antibodies cross the placenta and attack fetal red blood cells, causing hemolysis and hyperbilirubinemia. This process is the hallmark of Rh incompatibility-related pathology.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Which assessment finding in a newborn places them at risk for physiological jaundice?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When caring for a postpartum client, the nurse notes that the client's perineal pad is saturated with bright red blood.What is the priority to ask the client?

Correct Answer is A

Explanation

A nurse is caring for a client who has just delivered her first newborn.The nurse anticipates hyperbilirubinemia due to Rh incompatibility.The nurse should understand that hyperbilirubinemia occurs with Rh incompatibility for which of the following reasons?

Correct Answer is D

Explanation

A nurse is caring for a 5-year-old child who is postoperative following a tonsillectomy.Which of the following pain scales should the nurse use to determine the child's pain level?

Which of the following clients would the nurse report as a suspected abuse case?

A nurse is planning care for a preterm newborn.Which of the following nursing interventions to promote development should be included in the plan of care?

Which assessment finding would the nurse expect to find in a sexually active adolescent female concerned that she has contracted gonorrhea?

After receiving instruction on the use of a diaphragm for contraception, which statement by the client indicates that they have understood the teaching?

A nurse is assessing a postmature infant.Which of the following findings would the nurse expect? (Select all that apply.)

The nurse knows that which of the following is not a cause of mastitis?

Which assessment findings would alert the nurse to an infant or child in heart failure?