Within three days of birth, a newborn has developed a yellowish tinge that extends from the face to mid-chest is lethargic, and has to be awakened to feed. Which condition does the nurse suspect this infant is manifesting?
Physiologic jaundice
Pathologic jaundice
Breast milk jaundice
The Correct Answer is A
Physiologic jaundice usually appears between the second and fourth day after birth and resolves by the second week. It is caused by the immature liver's inability to process bilirubin efficiently.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Clear the respiratory tract. This is because clearing the respiratory tract is the first step in the initial care of a newborn following vaginal delivery. The respiratory tract includes the nose, mouth, and lungs.
Clearing the respiratory tract helps the baby breathe more easily and prevents aspiration of amniotic fluid, blood, or mucus. The nurse can use a bulb syringe or a suction device to gently remove any fluid from the baby's nose and mouth.

Choice B is not correct because drying the infant off and covering the head is not the first action to take. Drying and covering the infant helps prevent heat loss and hypothermia, which are important for newborn care. However, this should be done after clearing the respiratory tract.
Choice C is not correct because stimulating the infant to cry is not the first action to take. Stimulating the infant to cry can help expand the lungs and improve oxygenation, which is also important for newborn care. However, this should be done after clearing the respiratory tract.
Choice D is not correct because clamping the umbilical cord is not the first action to take. Clamping and cutting the umbilical cord separates the baby from the placenta, which is no longer needed after birth. However, this should be done after clearing the respiratory tract.
Correct Answer is C
Explanation
Tachycardia. Tachycardia is a sign of hypovolemic shock from postpartum hemorrhage, which occurs when the blood volume is reduced and the heart rate increases to compensate for the low cardiac output and tissue perfusion. Tachycardia is usually the first sign of hypovolemic shock, as it can occur even before a significant drop in blood pressure or other symptoms.
Choice A. Hypotension is incorrect because it is a late sign of hypovolemic shock, which occurs when the compensatory mechanisms fail to maintain adequate blood pressure and organ perfusion.
Choice B. Cold, clammy skin is incorrect because it is a sign of peripheral vasoconstriction, which occurs as a compensatory mechanism to divert blood flow to the vital organs. However, it is not specific to hypovolemic shock and can occur in other types of shock as well.
Choice D. Decreased urinary output is incorrect because it is a sign of renal impairment, which occurs as a result of reduced blood flow to the kidneys. However, it is not specific to hypovolemic shock and can occur in other types of shock or renal disorders as well.
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