Which tool provides the best assessment of neuromuscular and physical maturity correlating with gestational age of the newborn that the nurse can perform after birth?

Correct Answer: B

Rationale: The correct answer is B: Ballard score. The Ballard score is a tool used to assess neuromuscular and physical maturity in newborns, which correlates with their gestational age. It includes assessment of physical characteristics such as skin texture, lanugo, ear form, breast tissue, and genitalia. This assessment helps healthcare providers determine the newborn's gestational age more accurately. A: Apgar score assesses the newborn's overall health and vitality at one and five minutes after birth. C: Phenylketonuria (PKU) screening is a metabolic test to detect inherited disorders, not related to assessing maturity. D: Length and weight measurements provide important information but do not specifically assess neuromuscular and physical maturity correlating with gestational age.

Correct Answer: B

Rationale: The correct answer is B: Respiratory distress syndrome. In neonates, the most common cause of patent ductus arteriosus is the respiratory distress syndrome. This is because the hypoxia and acidosis associated with respiratory distress syndrome lead to the persistence of the ductus arteriosus. Oxygen therapy (A) may be needed in neonates with respiratory distress syndrome but is not the direct cause of patent ductus arteriosus. Genetic predisposition (C) is not a primary cause of patent ductus arteriosus in neonates. Necrotizing enterocolitis (D) is a condition affecting the intestines and is not directly related to the development of patent ductus arteriosus.

Correct Answer: C

Rationale: The correct answer is C: A premature infant with bronchopulmonary dysplasia. Premature infants with bronchopulmonary dysplasia are at the greatest risk for retinopathy of prematurity due to the prolonged exposure to oxygen therapy, which can lead to abnormal blood vessel growth in the retina. This condition can cause vision problems or even blindness. Choices A and B are common risk factors for prematurity but do not specifically increase the risk of retinopathy. Choice D, not receiving erythromycin ointment at birth, is unrelated to retinopathy risk.

Correct Answer: D

Rationale: The correct answer is D: Place temperature probe on the infant. This is the priority intervention as it helps monitor the neonate's temperature and prevent hypothermia or hyperthermia. Monitoring the infant's temperature is crucial for maintaining thermal stability. Placing pulse oximetry (choice A) is important but not as immediate as monitoring temperature. Placing leads (choice B) is not necessary for immediate thermal stability. Placing the infant in a polyurethane bag (choice C) is not recommended as it can increase the risk of hyperthermia.

Correct Answer: C

Rationale: The correct answer is C, maternal fever. Maternal fever is a significant risk factor for neonatal sepsis as it indicates an ongoing infection in the mother which can be transmitted to the baby during delivery. Fever is a common sign of infection, and neonates are particularly vulnerable to sepsis due to their immature immune systems. Rupture of membranes at delivery (choice A) can increase the risk of infection but is not as direct a risk factor as maternal fever. The father having the flu (choice B) is not directly related to maternal risk factors. History of herpes simplex virus (HSV) treated with Valtrex (choice D) is a concern, but maternal fever has a more immediate impact on neonatal sepsis risk.