A nurse in the newborn nursery is caring for a group of newborns. Which of the following newborns requires immediate intervention?
A newborn who is 12 hours post-delivery and has a temperature of 37.0°C (98.6°F).
A newborn who is 27 hours post-delivery and has not voided.
A newborn who is 18 hours post-delivery and has not passed meconium.
A newborn who is 18 hours post-delivery and has acrocyanosis.
The Correct Answer is B
Choice A rationale
A newborn with a temperature of 37.0°C (98.6°F) is within the normal range for newborns and does not require immediate intervention.
Choice B rationale
A newborn who has not voided within 27 hours post-delivery requires immediate intervention. Newborns should void within the first 24 hours of life. Failure to void may indicate dehydration, urinary tract obstruction, or renal issues.
Choice C rationale
A newborn who has not passed meconium within 18 hours post-delivery is concerning but not as urgent as not voiding. Newborns typically pass meconium within the first 24-48 hours.
Choice D rationale
Acrocyanosis, or bluish discoloration of the hands and feet, is common in newborns and usually resolves on its own. It does not require immediate intervention.
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Correct Answer is B
Explanation
Choice A rationale
Small for gestational age (SGA) refers to newborns whose birth weight is below the 10th percentile for their gestational age.
Choice B rationale
Appropriate for gestational age (AGA) refers to newborns whose birth weight is between the 10th and 90th percentiles for their gestational age. A newborn weighing 3350 g at 39 weeks gestation falls within this range.
Choice C rationale
Low birth weight is defined as a birth weight of less than 2500 g, which does not apply to this newborn.
Choice D rationale
Large for gestational age (LGA) refers to newborns whose birth weight is above the 90th percentile for their gestational age.
Correct Answer is B
Explanation
Choice A rationale
Administering only the Hepatitis B vaccine within 1 hour of birth is not sufficient for a newborn born to a Hepatitis B positive mother. The newborn also needs Hepatitis B immunoglobulin (HBIG) to provide immediate passive immunity.
Choice B rationale
Administering both the Hepatitis B vaccine and Hepatitis B immunoglobulin (HBIG) within 12 hours of delivery is the recommended practice for newborns born to Hepatitis B positive mothers. This provides both active and passive immunity.
Choice C rationale
Administering only Hepatitis B immunoglobulin (HBIG) within 12 hours of birth is not sufficient. The newborn also needs the Hepatitis B vaccine to develop long-term immunity.
Choice D rationale
Administering Hepatitis B immunoglobulin (HBIG) within 12 hours, followed by monthly Hepatitis B vaccines for 12 months, is not the standard practice. The newborn should receive the Hepatitis B vaccine series according to the recommended schedule. .