Page 854 - Saunders Comprehensive Review For NCLEX-RN

option, because this is a normal occurrence after circumcision.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Implementation
Content Area: Maternity: Newborn
Health Problem: Newborn: Circumcision
Priority Concepts: Clinical Judgment; Development
Reference: McKinney et al. (2018), pp. 471-472.

273. Answer: 1, 2, 4, 5

Rationale: A newborn infant with respiratory distress syndrome may present with
clinical signs of cyanosis, tachypnea or apnea, nasal flaring, chest wall retractions, or
audible grunts. Hypotension and a barrel chest are not clinical manifestations
associated with respiratory distress syndrome.
Test-Taking Strategy: Focus on the subject, signs of respiratory distress
syndrome. Eliminate hypotension, as this is not a finding associated with respiratory
distress syndrome. Also, respiratory distress syndrome is an acute occurrence, and a
barrel chest develops with a chronic condition. In addition, note the relationship
between the diagnosis and the signs noted in the correct options.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Assessment
Content Area: Maternity: Newborn
Health Problem: Newborn: Respiratory Problems
Priority Concepts: Gas Exchange; Perfusion
Reference: McKinney et al. (2018), p. 1053.

274. Answer: 2

Rationale: Hyperbilirubinemia is an elevated serum bilirubin level. At any serum
bilirubin level, the appearance of jaundice during the first day of life indicates a
pathological process. Early and frequent feeding hastens the excretion of bilirubin.
Breast-feeding should be initiated within 2 hours after birth and every 2 to 4 hours
thereafter. The infant should not be fed less frequently. Switching to bottle-feeding
for 2 weeks or stopping breast-feeding permanently is unnecessary.
Test-Taking Strategy: Eliminate options 3 and 4 because they are comparable or
alike. These options discourage the continuation of breast-feeding and should be
eliminated. From the remaining options, recalling the pathophysiology associated
with hyperbilirubinemia will assist you in eliminating option 1.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Teaching and Learning
Content Area: Maternity: Newborn
Health Problem: Newborn: Hyperbilirubinemia
Priority Concepts: Cellular Regulation; Client Education
Reference: McKinney et al. (2018), pp. 465, 467.

854