Which of the following findings should the nurse intervene for in a newborn immediately following a vaginal birth?

Sternal retractions

Molding

Acrocyanosis

Vernix caseosa

Answer and Explanation

The Correct Answer is A

Choice A reason: Sternal retractions indicate respiratory distress, as the newborn uses accessory muscles to breathe, suggesting airway obstruction or lung immaturity. This requires immediate intervention to ensure oxygenation, as it may reflect transient tachypnea or pneumothorax, compromising alveolar gas exchange, per neonatal respiratory physiology.

Choice B reason: Molding, the temporary reshaping of the skull during vaginal birth, is normal due to cranial bone flexibility. It resolves spontaneously within days and does not affect neurological or respiratory function, requiring no intervention, as it aligns with the biomechanics of vaginal delivery and neonatal adaptation.

Choice C reason: Acrocyanosis, bluish discoloration of hands and feet, is normal in newborns due to immature peripheral circulation. It resolves as vascular tone stabilizes and does not indicate hypoxia, requiring no intervention. This physiological adaptation reflects normal thermoregulatory and circulatory adjustments in the immediate postnatal period.

Choice D reason: Vernix caseosa, a waxy skin coating, is a normal protective layer in newborns, aiding thermoregulation and skin hydration. It requires no intervention, as it naturally absorbs or is gently cleaned. Vernix supports skin barrier function and antimicrobial defense, aligning with neonatal dermatological physiology.

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Correct Answer is A

Explanation

Choice A reason: A change in deep tendon reflexes from 4+ (hyperreflexic) to 2+ (normal) indicates magnesium sulfate’s therapeutic effect in preeclampsia, as it reduces neuronal excitability, preventing seizures. Magnesium stabilizes nerve membranes, lowering seizure risk by modulating calcium channels, aligning with its anticonvulsant role in preeclampsia management.

Choice B reason: A fetal heart rate increase from 150/min to 166/min is not a direct indicator of magnesium sulfate’s effectiveness. Magnesium primarily prevents maternal seizures, not fetal heart rate changes. This increase may reflect fetal stress or normal variation, unrelated to magnesium’s neurological stabilization in preeclampsia treatment.

Choice C reason: Minimal fetal heart rate variability suggests fetal compromise, not magnesium sulfate’s desired effect. Magnesium aims to prevent maternal seizures without significantly altering fetal heart patterns. Reduced variability may indicate hypoxia, requiring separate intervention, as it does not reflect the drug’s therapeutic goal of maternal neurological stabilization.

Choice D reason: Urinary output of 20 mL/hr indicates potential magnesium toxicity or renal impairment, not therapeutic effectiveness. Magnesium sulfate requires adequate renal excretion to avoid toxicity, and output below 30 mL/hr suggests accumulation, risking respiratory depression or cardiac effects, contrary to the drug’s intended anticonvulsant action in preeclampsia.

A. Assess for abdominal tenderness. B. Perform a fundal massage. C. Avoid performing sterile vaginal examinations. D. Obtain a specimen for a Kleihauer-Betke test.

Correct Answer is B

Explanation

Choice A reason: Assessing for abdominal tenderness does not address uterine atony or vaginal bleeding. Tenderness may indicate other issues, like infection, but atony requires immediate uterine contraction to control hemorrhage. Fundal massage directly stimulates myometrial contraction, addressing the primary cause of bleeding, per postpartum hemorrhage management protocols.

Choice B reason: Performing a fundal massage is the priority for uterine atony, as it stimulates myometrial contractions, promoting hemostasis at the placental site. Atony causes excessive bleeding due to poor uterine tone, and massage enhances oxytocin release, constricting blood vessels to reduce hemorrhage, aligning with obstetric emergency interventions.

Choice C reason: Avoiding sterile vaginal examinations does not address uterine atony or bleeding. Examinations assess cervical or vaginal trauma but do not correct myometrial failure. Atony requires active interventions like fundal massage to restore uterine tone and control hemorrhage, making this action irrelevant to the immediate physiological need.

Choice D reason: Obtaining a Kleihauer-Betke test assesses fetal-maternal hemorrhage, relevant for Rh-negative mothers, not uterine atony. Atony causes bleeding from poor uterine contraction, not fetal blood loss. This test does not address the immediate need to control hemorrhage through myometrial stimulation, per postpartum hemorrhage management principles.

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Which of the following findings should the nurse intervene for in a newborn immediately following a vaginal birth?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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