A nurse is admitting a term newborn following a cesarean birth. The nurse observes that the newborn's skin is slightly yellow. This finding indicates the newborn is experiencing a complication related to which of the following?

Correct Answer: A

Rationale: Step-by-step rationale for why the correct answer is A: 1. Maternal/newborn blood group incompatibility can result in hemolytic disease of the newborn. 2. Hemolytic disease causes an increase in bilirubin levels, leading to jaundice. 3. Jaundice in this case is due to the breakdown of red blood cells and elevated unconjugated bilirubin levels. 4. Physiologic jaundice is a normal process in newborns and usually appears after the first 24 hours of life. 5. Absence of vitamin K would not directly cause jaundice. 6. Maternal cocaine abuse is not typically associated with neonatal jaundice. In summary, the correct answer is A because maternal/newborn blood group incompatibility can lead to hemolytic disease and subsequent jaundice, while the other choices are not directly related to neonatal jaundice.

Correct Answer: D

Rationale: The correct answer is D. Ambulating a client with severe preeclampsia can be risky due to the potential for sudden worsening of symptoms and complications like seizures. It is important to prioritize rest and close monitoring in such cases. Assessing deep tendon reflexes every hour (A) is crucial as changes can indicate neurological involvement. Obtaining a daily weight (B) helps monitor fluid status. Continuous fetal monitoring (C) is necessary to assess the well-being of the fetus in cases of preeclampsia. In summary, ambulating the client with severe preeclampsia is the most concerning order as it may pose a significant risk to both the client and the fetus.

Correct Answer: A

Rationale: Step-by-step rationale for why the correct answer is A: 1. Maternal/newborn blood group incompatibility can result in hemolytic disease of the newborn. 2. Hemolytic disease causes an increase in bilirubin levels, leading to jaundice. 3. Jaundice in this case is due to the breakdown of red blood cells and elevated unconjugated bilirubin levels. 4. Physiologic jaundice is a normal process in newborns and usually appears after the first 24 hours of life. 5. Absence of vitamin K would not directly cause jaundice. 6. Maternal cocaine abuse is not typically associated with neonatal jaundice. In summary, the correct answer is A because maternal/newborn blood group incompatibility can lead to hemolytic disease and subsequent jaundice, while the other choices are not directly related to neonatal jaundice.

Correct Answer: A

Rationale: The correct answer is A: Increased blood pressure in the arms with decreased blood pressure in the legs. Coarctation of the aorta causes narrowing of the aorta, leading to increased blood pressure in the arms due to the pressure build-up before the narrowing and decreased blood pressure in the legs due to reduced blood flow beyond the narrowing. This pressure difference is a classic clinical manifestation of coarctation of the aorta. Choices B, C, and D are incorrect because they do not align with the pathophysiology of coarctation of the aorta. B is incorrect as decreased blood pressure in the arms is not typical. C is incorrect as increased blood pressure in both the arms and legs does not reflect the characteristic pressure difference caused by the aortic narrowing. D is incorrect as decreased blood pressure in both the arms and legs is not consistent with the presentation of coarctation of the aorta.

Correct Answer: C

Rationale: During a Leopold maneuver, if the healthcare professional determines that the fetus is in an RSA position, it means the fetal back is on the right side, and the small parts are on the left side, indicating a breech presentation. Therefore, the correct answer is C: Breech. The other choices are incorrect because: A: Vertex refers to the head-first position. B: Shoulder presentation would involve feeling the shoulder first during the maneuver. D: Mentum presentation would involve feeling the chin first, which is not the case in an RSA position.

Correct Answer: D

Rationale: The correct answer is D: Fetal position is persistent occiput posterior. This position, where the baby's head is facing the mother's abdomen instead of her back, can lead to severe backache and difficulty during labor due to increased pressure on the mother's spine. This malposition can impede the progress of labor and cause prolonged labor. Explanation of incorrect choices: A: Fetal attitude in general flexion is a normal position and not typically associated with severe backache. B: Fetal lie being longitudinal refers to the baby's position in relation to the mother's spine and is not directly related to backache. C: Maternal pelvis being gynecoid is a favorable shape for childbirth and is unlikely to cause severe backache during labor.

Correct Answer: A

Rationale: The correct action for the nurse to take first is to evaluate the firmness of the uterus. This is because the client's low blood pressure may indicate postpartum hemorrhage, which is a common complication after childbirth. Assessing the firmness of the uterus helps determine if there is uterine atony, a leading cause of postpartum hemorrhage. By addressing uterine atony promptly, the nurse can prevent further blood loss and stabilize the client's condition. Summary: - Option B, initiating oxygen therapy, is not the first priority as the client's low blood pressure is likely due to hemorrhage rather than hypoxemia. - Option C, administering oxytocin infusion, may be necessary to address uterine atony but should only be done after assessing the firmness of the uterus. - Option D, obtaining a type and crossmatch, is important for potential blood transfusion but is not the immediate priority compared to assessing for uterine atony.

Correct Answer: D

Rationale: The correct interpretation of 0 station is that the lowermost portion of the fetus is at the level of the ischial spines. This indicates the descent of the fetus into the birth canal. At 0 station, the presenting part has not yet passed through the pelvic outlet, ruling out choice B. Choices A and C are incorrect as they refer to different aspects of fetal positioning and fontanel palpation, not specifically related to station. Therefore, the correct answer is D as it directly relates to the position of the fetus in the birth canal.

Correct Answer: B

Rationale: The correct answer is B: Offer the option to view products of conception. This intervention allows the client to have closure and process the loss. It can also provide emotional support and facilitate the grieving process. Option A is not necessary unless the client is hypoxic. Option C is not relevant to the immediate management of an inevitable abortion. Option D may be advised for some clients, but it is not as crucial as offering emotional support and closure to the client in this situation.