Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A. Increased risk of anemia
Increased risk of anemia is not a likely cause of respiratory distress in a term macrosomic newborn, as it can affect any newborn regardless of the maternal diabetes status or the fetal size. Anemia can cause pallor, tachycardia, and poor feeding, but not respiratory distress.
B. Hyperinsulinemia
Hyperinsulinemia is a likely cause of respiratory distress in a term macrosomic newborn, as it results from the fetal exposure to high maternal glucose levels and the subsequent overproduction of insulin. Hyperinsulinemia can impair the synthesis of surfactant, which is a substance that prevents the alveoli from collapsing and facilitates gas exchange. Hyperinsulinemia can also cause hypoglycemia, which can affect the respiratory center and cause apnea.
C. Increased blood viscosity
Increased blood viscosity is not a likely cause of respiratory distress in a term macrosomic newborn, as it can affect any newborn with polycythemia, which is an abnormally high number of red blood cells. Polycythemia can cause cyanosis, jaundice, and thrombosis, but not respiratory distress.
D. Brachial plexus injury
Brachial plexus injury is not a likely cause of respiratory distress in a term macrosomic newborn, as it affects the nerves that supply the arm and hand, not the lungs. Brachial plexus injury can occur due to the excessive traction or stretching of the shoulder during delivery, and can cause weakness, paralysis, or sensory loss in the affected arm.
This question is an excerpt from Nurse Dive's nursing test bank - ATI Maternal Newborn Proctored Exam 4. Take the full exam now
Full Explanation
Choice A reason: Increased risk of anemia is not a likely cause of respiratory distress in a term macrosomic newborn, as it can affect any newborn regardless of the maternal diabetes status or the fetal size. Anemia can cause pallor, tachycardia, and poor feeding, but not respiratory distress.
Choice B reason: Hyperinsulinemia is a likely cause of respiratory distress in a term macrosomic newborn, as it results from the fetal exposure to high maternal glucose levels and the subsequent overproduction of insulin. Hyperinsulinemia can impair the synthesis of surfactant, which is a substance that prevents the alveoli from collapsing and facilitates gas exchange. Hyperinsulinemia can also cause hypoglycemia, which can affect the respiratory center and cause apnea.
Choice C reason: Increased blood viscosity is not a likely cause of respiratory distress in a term macrosomic newborn, as it can affect any newborn with polycythemia, which is an abnormally high number of red blood cells. Polycythemia can cause cyanosis, jaundice, and thrombosis, but not respiratory distress.
Choice D reason: Brachial plexus injury is not a likely cause of respiratory distress in a term macrosomic newborn, as it affects the nerves that supply the arm and hand, not the lungs. Brachial plexus injury can occur due to the excessive traction or stretching of the shoulder during delivery, and can cause weakness, paralysis, or sensory loss in the affected arm.
Similar Questions
A pregnant woman was admitted for induction of labor at 43 weeks of gestation with sure dates. A nonstress test (NST) in the obstetrician's office revealed a nonreactive tracing. On artificial rupture of membranes, thick meconium-stained fluid was noted. What should the nurse caring for the infant after birth anticipate?
A. Meconium aspiration, hypoglycemia, and dry, cracked skin
This statement is correct, as these are the common complications of post-term infants, who are born after 42 weeks of gestation. Meconium aspiration can occur when the fetus passes meconium in utero and inhales it into the lungs, causing respiratory distress, inflammation, and infection. Hypoglycemia can occur due to the depletion of glycogen stores and the increased metabolic demands. Dry, cracked skin can occur due to the loss of vernix caseosa and the reduced amniotic fluid.
B. Hyperglycemia, hyperthermia, and an alert, wide-eyed appearance
This statement is incorrect, as these are the signs of neonatal hypocalcemia, which is a low level of calcium in the blood. Neonatal hypocalcemia can occur due to maternal diabetes, prematurity, or asphyxia, and can cause jitteriness, seizures, or tetany.
C. Excessive vernix caseosa covering the skin, lethargy, and RDS
This statement is incorrect, as these are the characteristics of preterm infants, who are born before 37 weeks of gestation. Excessive vernix caseosa covering the skin is a protective coating that prevents heat and water loss. Lethargy and RDS are signs of immaturity and underdevelopment of the central nervous system and the lungs.
D. Golden yellow to green-stained skin and nails, absence of scalp hair, and an increased amount of subcutaneous fat
This statement is incorrect, as these are the features of infants with erythroblastosis fetalis, which is a hemolytic disease caused by the incompatibility of the Rh factor or the ABO blood group between the mother and the fetus. Golden yellow to green-stained skin and nails are due to the accumulation of bilirubin, which is a breakdown product of red blood cells. Absence of scalp hair and an increased amount of subcutaneous fat are due to the chronic hypoxia and edema.
Full Explanation
Choice A reason: This statement is correct, as these are the common complications of post-term infants, who are born after 42 weeks of gestation. Meconium aspiration can occur when the fetus passes meconium in utero and inhales it into the lungs, causing respiratory distress, inflammation, and infection. Hypoglycemia can occur due to the depletion of glycogen stores and the increased metabolic demands. Dry, cracked skin can occur due to the loss of vernix caseosa and the reduced amniotic fluid.
Choice B reason: This statement is incorrect, as these are the signs of neonatal hypocalcemia, which is a low level of calcium in the blood. Neonatal hypocalcemia can occur due to maternal diabetes, prematurity, or asphyxia, and can cause jitteriness, seizures, or tetany.
Choice C reason: This statement is incorrect, as these are the characteristics of preterm infants, who are born before 37 weeks of gestation. Excessive vernix caseosa covering the skin is a protective coating that prevents heat and water loss. Lethargy and RDS are signs of immaturity and underdevelopment of the central nervous system and the lungs.
Choice D reason: This statement is incorrect, as these are the features of infants with erythroblastosis fetalis, which is a hemolytic disease caused by the incompatibility of the Rh factor or the ABO blood group between the mother and the fetus. Golden yellow to green-stained skin and nails are due to the accumulation of bilirubin, which is a breakdown product of red blood cells. Absence of scalp hair and an increased amount of subcutaneous fat are due to the chronic hypoxia and edema.
A nurse in a provider's office is caring for a client who is at 34 weeks of gestation and at risk for placental abruption. The nurse should recognize that which of the following is the most common risk factor for abruption?
A. Blunt force trauma
Blunt force trauma is a possible risk factor for placental abruption, which is a condition where the placenta detaches from the uterine wall and causes bleeding, pain, and fetal distress. However, blunt force trauma is not the most common risk factor, as it accounts for only a small percentage of cases. The most common causes of blunt force trauma are motor vehicle accidents, falls, or domestic violence.
B. Hypertension
Hypertension is the most common risk factor for placental abruption, as it affects about 50% of cases. Hypertension can cause vasospasm and reduced blood flow to the placenta, which can weaken the attachment and lead to separation. Hypertension can be chronic, gestational, or related to preeclampsia.
C. Gestational diabetes mellitus
Gestational diabetes mellitus is not a risk factor for placental abruption, but rather a condition where the client develops high blood sugar levels during pregnancy and can cause complications, such as macrosomia, polyhydramnios, or neonatal hypoglycemia. Gestational diabetes mellitus does not affect the placental attachment or function.
D. Cigarette smoking
Cigarette smoking is a risk factor for placental abruption, as it can cause vasoconstriction and reduced oxygen delivery to the placenta, which can impair its growth and development. However, cigarette smoking is not the most common risk factor, as it affects about 25% of cases.
Full Explanation
Choice A reason: Blunt force trauma is a possible risk factor for placental abruption, which is a condition where the placenta detaches from the uterine wall and causes bleeding, pain, and fetal distress. However, blunt force trauma is not the most common risk factor, as it accounts for only a small percentage of cases. The most common causes of blunt force trauma are motor vehicle accidents, falls, or domestic violence.
Choice B reason: Hypertension is the most common risk factor for placental abruption, as it affects about 50% of cases. Hypertension can cause vasospasm and reduced blood flow to the placenta, which can weaken the attachment and lead to separation. Hypertension can be chronic, gestational, or related to preeclampsia.
Choice C reason: Gestational diabetes mellitus is not a risk factor for placental abruption, but rather a condition where the client develops high blood sugar levels during pregnancy and can cause complications, such as macrosomia, polyhydramnios, or neonatal hypoglycemia. Gestational diabetes mellitus does not affect the placental attachment or function.
Choice D reason: Cigarette smoking is a risk factor for placental abruption, as it can cause vasoconstriction and reduced oxygen delivery to the placenta, which can impair its growth and development. However, cigarette smoking is not the most common risk factor, as it affects about 25% of cases.
A nurse is providing care to a mother immediately following a stillbirth delivery. Which of the following actions should the nurse take first?
A. Assist the client with transferring to the gynecology unit.
Assisting the client with transferring to the gynecology unit is not the first action that the nurse should take, as it does not address the client's emotional needs or preferences. The nurse should first assess the client's coping and grieving process, and provide support and comfort.
B. Offer the mother private time with the newborn.
Offering mother private time with the newborn is the first action that the nurse should take, as it can facilitate the bonding and closure process, and help the client express her feelings and emotions. The nurse should respect the client's wishes and cultural beliefs regarding the viewing and holding of the stillborn infant, and provide a quiet and private environment.
C. Administer alprazolam 0.5 mg PO.
Administering alprazolam 0.5 mg PO is not the first action that the nurse should take, as it is a pharmacological intervention that requires a prescription and an assessment of the client's condition and history. The nurse should first use nonpharmacological methods, such as active listening, therapeutic communication, and counseling, to help the client cope and manage her anxiety and grief.
D. Contact the health care facility's clergy.
Contacting the health care facility's clergy is not the first action that the nurse should take, as it may not be appropriate or desired by the client. The nurse should first ask the client if she wants any spiritual or religious support, and respect her decision and beliefs.
Full Explanation
Choice A reason: Assisting the client with transferring to the gynecology unit is not the first action that the nurse should take, as it does not address the client's emotional needs or preferences. The nurse should first assess the client's coping and grieving process, and provide support and comfort.
Choice B reason: Offering the mother private time with the newborn is the first action that the nurse should take, as it can facilitate the bonding and closure process, and help the client express her feelings and emotions. The nurse should respect the client's wishes and cultural beliefs regarding the viewing and holding of the stillborn infant, and provide a quiet and private environment.
Choice C reason: Administering alprazolam 0.5 mg PO is not the first action that the nurse should take, as it is a pharmacological intervention that requires a prescription and an assessment of the client's condition and history. The nurse should first use nonpharmacological methods, such as active listening, therapeutic communication, and counseling, to help the client cope and manage her anxiety and grief.
Choice D reason: Contacting the health care facility's clergy is not the first action that the nurse should take, as it may not be appropriate or desired by the client. The nurse should first ask the client if she wants any spiritual or religious support, and respect her decision and beliefs.