Chapter 17: Physiological Transition of the Newborn Nursing School Test Banks

Chapter 17: Physiological Transition of the Newborn

MULTIPLE CHOICE

1. A woman gives birth to a healthy baby boy at 35 weeks gestation. What factor regarding the development of the normal respiratory system should the nurse consider when performing an assessment of the neonate?
A. As the fetus approaches term, secretion of intrapulmonary fluid increases.
B. Lung expansion after birth suppresses the further release of surfactant.
C. Surfactant increases alveolar surface tension, allowing re-expansion after exhalation.
D. Surfactant production is sufficient to maintain alveolar stability by about 34 weeks.
ANS: D
As the fetus approaches term, there is a decrease in the secretion of intrapulmonary fluid, which assists in reducing the pulmonary resistance to blood flow and facilitates the initiation of air breathing. Lung expansion after birth stimulates the release of surfactanta slippery, detergent-like lipoprotein. Surfactant causes decreased surface tension within the alveoli, which allows for alveolar re-expansion following each exhalation. Under normal circumstances, by the 34th to 36th week of gestation, surfactant is produced in sufficient amounts to maintain alveolar stability.

Cognitive Level: Knowledge/Remembering
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Nursing Process: Assessment
Difficulty: Easy

PTS: 1

2. A nurse in the high-risk obstetrical unit monitors a student nurse preparing to give a patient a dose of betamethasone (Celestone). Which action by the student warrants intervention by the nurse?
A. Assesses the patients lung sounds prior to administration
B. Draws up 12 mg in a syringe with a 20-gauge needle
C. Gently shakes the medication before drawing it up
D. Prepares to administer medication in the deltoid muscle
ANS: D
Betamethasone should not be administered in the deltoid muscle, as it can cause local atrophy. It needs to be given in a larger muscle. The other actions are appropriate for this medication.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Pharmacological and Parenteral Therapies
Integrated Process: Nursing Process: Implementation
Difficulty: Difficult

PTS: 1

3. A perinatal nurse has orders to administer betamethasone (Celestone) to the following women in preterm labor. For which patient should the nurse question this order?
A. Emergency cesarean section
B. Fetal cardiac abnormalities
C. Maternal diabetes
D. Severe preeclampsia/eclampsia
ANS: D
Betamethasone is contraindicated in women in whom there is a medical indication for childbirth (e.g., severe preeclampsia/eclampsia, cord prolapse, chorioamnionitis, abruptio placentae) and in women with systemic fungal infection.

Cognitive Level: Analysis/Analyzing
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Pharmacological and Parenteral Therapies
Integrated Process: Communication and Documentation
Difficulty: Difficult

PTS: 1

4. The perinatal nurse explains the cardiopulmonary adaptations that occur in the neonate to a student nurse. Which of the following statements accurately describes the sequence of these changes?
A. As air enters the lungs, the PO2 rises in the alveoli, which causes pulmonary artery relaxation and results in an increase in pulmonary vascular resistance.
B. As the pulmonary vascular resistance increases, pulmonary blood flow increases, reaching 100% by the first 24 hours of life.
C. Decreased pulmonary blood volume contributes to the conversion from fetal to newborn circulation.
D. Once the pulmonary circulation has been functionally established, blood is distributed throughout the lungs.
ANS: D
As air enters the lungs, the PO2 rises in the alveoli. This normal physiological response causes pulmonary artery relaxation and results in a decrease in pulmonary vascular resistance. As the pulmonary vascular resistance decreases, pulmonary blood flow increases, reaching 100% by the first 24 hours of life. The increased pulmonary blood volume contributes to the conversion from fetal to newborn circulation. Once the pulmonary circulation has been functionally established, blood is distributed throughout the lungs. The other explanations are inaccurate.

Cognitive Level: Comprehension/Understanding
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Teaching/Leaning
Difficulty: Moderate

PTS: 1

5. The nurse is assessing the cardiovascular status of a newborn. Which of the following findings indicates adequate systemic circulation?
A. Capillary refill 2 seconds
B. Capillary refill 4 seconds
C. Pale mucous membranes in a dark-skinned baby
D. Truncal cyanosis
ANS: A
On assessment, the systemic circulation is deemed adequate if the newborn exhibits a brisk capillary refill and stable blood pressure. Capillary refill in less than 3 seconds is considered adequate. A refill time greater than 4 seconds may be indicative of an underlying condition, such as sepsis, hypoxia, or cardiovascular or central nervous system compromise. A dark-skinned baby should have pink mucous membranes. Acrocyanosis is normal, but a cyanotic trunk is not.

Cognitive Level: Knowledge/Remembering
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Nursing Process: Assessment
Difficulty: Moderate

PTS: 1

6. New parents are concerned that after initially breastfeeding their baby 2 hours after being born, she is sleeping soundly and will not awaken. What action by the nurse is most appropriate?
A. Call the rapid response team.
B. Document the neonates behavior in the chart.
C. Reassure the parents that this is normal.
D. Stimulate the baby to wake her up.
ANS: C
After the initial period of reactivity, the infant falls into a deep sleep from which she is difficult to arouse. The nurse should reassure the parents that this is normal. Documentation is important, but the nurse first needs to care for the parents and baby by giving the parents information on normal newborn behaviors. Calling the rapid response team and stimulating the baby are both unnecessary.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Health Promotion and Maintenance
Integrated Process: Teaching/Learning
Difficulty: Moderate

PTS: 1

7. A nurse suspects that an infant in the intensive care unit has had intrauterine exposure to one of the TORCH infections. What finding is indicative of in utero exposure to a TORCH infection?
A. Decreased IgA
B. Decreased IgG
C. Increased IgG
D. Increased IgM
ANS: D
Elevations in IgM can occur as a result of exposure to an intrauterine infection or one of the TORCH infections.

Cognitive Level: Knowledge/Remembering
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Reduction of Risk Potential
Integrated Process: Nursing Process: Assessment
Difficulty: Difficult

PTS: 1

8. A neonatal nurse who is caring for newborns suggests the best time for a mother to first attempt breastfeeding is during which of the following stages of activity?
A. First period of inactivity and sleep
B. First period of reactivity
C. Second period of inactivity and sleep
D. Second period of reactivity
ANS: B
The best stage for initiating breastfeeding is the first period of reactivity, which is the first period of active alert wakefulness that the infant displays immediately after birth. This first period of reactivity is an opportune time for the mother to initiate breastfeeding, if she wishes to do so.

Cognitive Level: Knowledge/Remembering
Content Area: Pediatrics/Maternity
Patient Needs: Health Promotion and Maintenance
Integrated Process: Teaching/Learning
Difficulty: Easy

PTS: 1

9. The nurse caring for a woman about to deliver a baby at 33 weeks gestation knows that what factor might have accelerated surfactant production?
A. Fetal hemolytic disorders
B. Incorrect dates
C. Maternal hypertension
D. Multiple gestation
ANS: C
A fetus has produced sufficient surfactant for independent respiratory function by about gestational weeks 34 to 36. Hence, a baby born at 33 weeks gestation is at risk for not having enough surfactant. Factors that can lead to increased surfactant production include mothers with White classification D, F, and R diabetes; maternal hypertension; and maternal heroin addiction. Fetal hemolytic disorders and multiple gestation are risk factors for decreased surfactant production. Incorrect dates may be important, but this is not a factor that leads to increased surfactant production.

Cognitive Level: Knowledge/Remembering
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Nursing Process: Assessment
Difficulty: Moderate

PTS: 1

10. The nursing professor is explaining to a class of students that which chemical factor in the blood directly leads to the initiation of respirations in the newborn?
A. Bilirubin
B. Carbon dioxide
C. High arterial pH
D. Low arterial pH
ANS: B
All newborns have a brief period of asphyxia during which they become hypoxic, leading to lowered pH. Subsequently carbon dioxide levels begin to rise and this stimulates the respiratory center in the brain to initiate respirations.

Cognitive Level: Comprehension/Understanding
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Teaching/Learning
Difficulty: Moderate

PTS: 1

11. What action by the nurse is most important to prevent respiratory depression in a newly born infant?
A. Bathe the infant in warm water before giving to the mother.
B. Dress the infant in warm clothing and place in a warmer.
C. Dry the infant and place on the mothers bare chest.
D. Turn the delivery room temperature up to 85F (29.4C).
ANS: C
Cold stress can lead to respiratory depression. The nurse should immediately dry off a newly born infant and either place him in skin-to-skin contact with the mother or put him in a radiant warmer.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Nursing Process: Implementation
Difficulty: Moderate

PTS: 1

12. A nurse assesses a 2-hour-old infants temperature and notes it to be 97.7F (36.5C). What action by the nurse is most appropriate?
A. Document the findings and continue to monitor.
B. Ensure the baby is wearing a hat.
C. Place the baby in a pre-warmed incubator.
D. Tightly swaddle the baby.
ANS: A
A normal axillary temperature for an infant is 97.798.6 F (36.537 C) within 23 hours after birth. The nurse should document the findings and continue to monitor per institutional policy. No further action is needed.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Communication and Documentation
Difficulty: Easy

PTS: 1

13. A new mother with a 6-hour-old infant calls the nursing station complaining that her baby is so cold he is shivering. What action by the nurse is most appropriate?
A. Bring warm blankets to wrap the baby in.
B. Encourage the mother to feed him a warmed bottle.
C. Perform a thorough head-to-toe assessment.
D. Set the room temperature higher.
ANS: C
Infants are unable to shiver to produce heat. They produce heat through a mechanism called nonshivering thermogenesis. A report by the mother of an infant shivering requires a thorough investigation and assessment for problems such as seizures. The other actions are not needed.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Nursing Process: Assessment
Difficulty: Moderate

PTS: 1

14. What action by the nurse is most important to prevent hemorrhagic disease of the newborn?
A. Administer vitamin K1 phytonadione (AquaMEPHYTON).
B. Assess daily hemoglobin and hematocrit levels.
C. Coordinate laboratory sticks to minimize blood loss.
D. Handle the infant gently to prevent injury.
ANS: A
Infants are given one dose of vitamin K during initial care and assessment to prevent hemorrhagic disease of the newborn. Assessing laboratory values does not prevent a condition from occurring, but it might alert health-care providers to changes in status. Minimizing blood loss and gentle handling do not prevent hemorrhagic disease, although both are good ideas for other reasons.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Pharmacological and Parenteral Therapies
Integrated Process: Nursing Process: Implementation
Difficulty: Moderate

PTS: 1

15. A nurse is assessing a newborn who is jittery, diaphoretic, and hypothermic, and has poor feeding. What laboratory value would the nurse correlate with this condition?
A. Bilirubin: 5 mg/dL
B. Blood glucose: 32 mg/dL
C. Hematocrit: 50%
D. White blood cell count: 25,000/mm3
ANS: B
This infant has signs of hypoglycemia, confirmed with a blood glucose level below 40 mg/dL (normal is 4060 mg/dl). The other laboratory values are normal for a neonate.

Cognitive Level: Analysis/Analyzing
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Reduction of Risk Potential
Integrated Process: Nursing Process: Assessment
Difficulty: Difficult

PTS: 1

16. A healthy term infant is being discharged at 48 hours of age. When should the nurse instruct the mother to follow up with a bilirubin assessment?
A. Within 24 hours
B. Within 2448 hours
C. Within 5 days
D. In 1 week
ANS: C
Healthy term infants discharged between 48 and 72 hours should receive follow-up and bilirubin assessment within 5 days.

Cognitive Level: Comprehension/Understanding
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Reduction of Risk Potential
Integrated Process: Teaching/Learning
Difficulty: Easy

PTS: 1

17. A term infant is 22 hours old, has a total serum bilirubin level of 13 mg/dL, and has visible jaundice. What action by the nurse is most appropriate?
A. Assure the parents that this is temporary.
B. Document the findings in the infants chart.
C. Have the mother switch to bottle feeding.
D. Review the chart for history of a traumatic birth.
ANS: D
Jaundice that appears within the first 24 hours of life is considered pathological. Causes can include events that lead to excessive breakdown of RBCs, leading to increased bilirubin levels, such as polycythemia, traumatic birth, infection, metabolic disorders, and Rh incompatibility. The diagnosis is made when total serum bilirubin levels rise higher than 12.9 mg/dL in term infants and 15 mg/dL in preterm infants. The nurse should review the chart for evidence of a traumatic birth. The other actions are not warranted.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Nursing Process: Assessment
Difficulty: Moderate

PTS: 1

18. A mother brings her 1-week-old baby to the clinic with complaints that the baby is not eating well. The mother is attempting to bottle feed about 120 mL every 2 hours. What action by the nurse is best?
A. Explain that this is too much volume at one time.
B. Have the mother demonstrate her feeding and burping technique.
C. Reassure the mother that the baby is eating fine.
D. Weigh the baby and plot her weight on a graph.
ANS: A
At 1 week of age, an infants stomach has a capacity of about 90 mL. Attempting to feed 120 mL is too much at one time. Weighing the baby and plotting her growth and having the mother demonstrate feeding and burping techniques are not incorrect, but the mother needs additional information to safely feed her baby. Simply reassuring the mother does not give her the information she needs to feed the baby appropriately.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Health Promotion and Maintenance
Integrated Process: Teaching/Learning
Difficulty: Moderate

PTS: 1

19. A nursing student asks the registered nurse why babies get dehydrated so easily. What response by the nurse is most accurate?
A. Babies are so tiny that a small water loss leads to big problems.
B. Infants tend to lose more water through insensible losses.
C. Because they dont drink much at a time, skipping a feeding is harmful.
D. Infants long intestines have more surface area from which to lose water.
ANS: D
Babies intestines are proportionally longer than adults. This gives them more surface area from which to absorb nutrients, but also more surface area from which to lose water when they have diarrhea, leading to rapid dehydration.

Cognitive Level: Comprehension/Understanding
Content Area: Pediatrics/Maternity
Patient Needs: Health Promotion and Maintenance
Integrated Process: Teaching/Learning
Difficulty: Moderate

PTS: 1

20. A motherbaby nurse assesses newborns for their risk of developing hypoglycemia. Which infant would the nurse assess as being at highest risk?
A. Asian ethnic background
B. Delayed feedings after birth
C. Infant with heat stress
D. Maternal use of terbutaline (Brethine)
ANS: D
Several risk factors for hypoglycemia exist, including pre- or post-maturity, intrauterine growth restriction, large or small for gestational age, asphyxia, difficult transition at birth, cold stress, maternal diabetes or preeclampsia-eclampsia, terbutaline use, infection, and congenital malformations.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Health Promotion and Maintenance
Integrated Process: Nursing Process: Assessment
Difficulty: Difficult

PTS: 1

21. What assessment finding indicates to the nurse that goals for the diagnosis of ineffective thermoregulation related to newborns immature temperature regulatory system have been met?
A. Axillary temperature is 98.1F (36.7C).
B. Fluctuations in infants temperature cease.
C. Baby stops shivering and falls asleep.
D. Rectal temperature is 101.0F (38.3C).
ANS: A
The normal range for newborn temperature is 97.798.6F (36.537.0C). A stable temperature within this range demonstrates that goals for this diagnosis have been met. Fluctuations in infants temperature cease is vague, and the temperature may have stabilized at a level that is too high or too low. Infants cant shiver. Axillary, not rectal, temperatures are taken; the temperature may also be assessed via continuous skin probe, or tympanic or temporal artery thermometry.

Cognitive Level: Evaluation/Evaluating
Content Area: Pediatrics/Maternity
Patient Needs: Health Promotion and Maintenance
Integrated Process: Nursing Process: Evaluation
Difficulty: Difficult

PTS: 1

MULTIPLE RESPONSE

1. The clinical nurse recalls that the newborn has mechanisms by which heat is lost following birth. Which of the following are examples of heat lost via convection? (Select all that apply.)
A. Placed near an open window
B. Placed on a cold scale
C. Placed under a ceiling fan
D. Not dried adequately after birth
E. Placed in a warmer that is not yet warm
ANS: A, C
Evaporation is the loss of heat that occurs when water is converted into a vapor, such as inadequately dried skin. Conduction is the loss of heat to a cooler surface by direct skin contact, such as when the infant is placed on a cold surface. Convective heat loss occurs when the neonate is exposed to drafts and cool circulating air, such as being placed near an open window or fan.

Cognitive Level: Knowledge/Remembering
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Nursing Process: Assessment
Difficulty: Easy

PTS: 1

2. A perinatal nurse suspects that a newborn may be experiencing polycythemia. What further assessments should be made to confirm this condition? (Select all that apply.)
A. Heel stick for metabolic screen
B. Hematocrit level
C. Hemoglobin level
D. Respiratory rate
E. White blood cell count
ANS: B, C, D
Polycythemia, which is an abnormally high erythrocyte count, can place the infant at high risk for jaundice and organ damage due to increased viscosity of the blood cells. A peripherally drawn hematocrit for a normal infant ranges from 48 to 64%. If the hematocrit drawn from a central site is greater than 65%, the infant is considered to be polycythemic. Polycythemic infants are also at an increased risk for hypoglycemia and respiratory distress; therefore, hemoglobin levels and the respiratory rate should be assessed.

Cognitive Level: Analysis/Analyzing
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Reduction of Risk Potential
Integrated Process: Nursing Process: Assessment
Difficulty: Difficult

PTS: 1

3. The clinical nurse assesses kidney function in a newborn. Which of the following statements accurately describes the development of normally functioning kidneys in the newborn? (Select all that apply.)
A. The glomerular filtration rate rapidly increases during the first 4 months of life.
B. The glomerular filtration rate is higher than that of the adult.
C. The kidneys are not mature and fully functional until after birth.
D. The nephrons are fully functional by 29 to 32 weeks of gestation.
E. Urine specific gravity in a neonate ranges from 1.002 to 1.010.
ANS: A, C, E
As the kidneys mature and enlarge, the glomerular filtration rate rapidly increases during the first 4 months of life. The nephrons are fully functional by 34 to 36 weeks of gestation. The glomerular filtration rate is lower than that of the adult.
Although the fetal kidneys contain working nephrons by 34 to 36 weeks of gestation, the kidneys are not mature and fully functional until after birth, when the newborn becomes responsible for the elimination of waste products. Normal specific gravity in the neonates urine ranges from 1.002 to 1.010.

Cognitive Level: Knowledge/Remembering
Content Area: Pediatrics/Maternity
Patient Needs: Health Promotion and Maintenance
Integrated Process: Nursing Process: Assessment
Difficulty: Difficult

PTS: 1

4. A perinatal nurse assesses a term newborn for respiratory functioning. The nurse will document which of the following findings as normal for a neonate? (Select all that apply.)
A. Breathing pattern that can be shallow, diaphragmatic, and irregular
B. Periodic episodes of apnea
C. Respiratory rate of 2040 breaths/minute while sleeping
D. Respiratory rate of 6080 breaths/minute
E. The neonates lung sounds are moist during early auscultation
ANS: A, E
The normal respiratory rate for a healthy term newborn is 4060 breaths/minute, whether awake or sleeping. The breathing pattern is often shallow, diaphragmatic, and irregular. Apnea is cessation of breathing that lasts more than 20 seconds; it is abnormal in the term neonate. Most fetal fluid is reabsorbed within the first few hours, but in some infants this process may take up to 24 hours, and the lungs may sound moist for the first 24 hours.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Communication and Documentation
Difficulty: Easy

PTS: 1

5. A pregnant woman at 25 weeks of gestation visits the prenatal clinic for a checkup. She asks the nurse how the baby is able to breathe on his own following childbirth. The nurse plans to explain the factors that influence the initiation of the newborns first breath, including which of the following?
A. A quiet environment
B. Drastic change in temperature
C. Hypoxia
D. Initiation of breastfeeding
E. Recoil of the chest wall after delivery of the trunk
ANS: B, C, E
Hypoxia causes blood oxygen levels (PO2) and pH to drop. Subsequently, blood carbon dioxide levels (PCO2) begin to rise and prompt the respiratory center within the medulla to initiate breathing. Once the fetus moves from the intrauterine to the extrauterine environment, the drastic change in temperature helps to stimulate the initiation of respirations, because sensors in the skin respond to the temperature changes and send signals to the respiratory system in the brain. Recoil of the chest wall after delivery of the neonates trunk creates a negative intrathoracic pressure, which facilitates a small, passive inspiration of air. An extremely sensory-overloaded environment filled with a multitude of tactile, visual, and auditory stimuli aids in the initiation of respirations.
A quiet environment and breastfeeding do not assist in the initiation of independent respiratory function.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Teaching/Learning
Difficulty: Moderate

PTS: 1

6. The nursing instructor is explaining passive acquired immunity to a class of nursing students. What information does the professor include? (Select all that apply.)
A. Cellular immunity is the mediator of passive acquired immunity.
B. Colostrum and breast milk are important sources of IgA.
C. IgG passes through the placenta before birth.
D. Most immunity is acquired in the first trimester.
E. Passive acquired immunity generally lasts 6 months.
ANS: B, C, E
Passive acquired immunity is mediated through humoral antibodies, primarily IgA, IgG, and IgM. Colostrum and breast milk are important sources of IgA, which is important in fighting respiratory and gastrointestinal disorders. IgG is able to pass through the placenta. Most passive acquired immunity is acquired in the third trimester and lasts approximately 6 months.

Cognitive Level: Comprehension/Understanding
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Teaching/Learning
Difficulty: Difficult

PTS: 1

7. The perinatal nurse teaches new parents about the stages of infant behavior. What information does the nurse provide? (Select all that apply.)
A. Excessive motor activity occurs in the wide-awake state.
B. Irregular respirations are common in REM sleep.
C. Jerking movements may accompany crying.
D. Stimulation decreases activity in the active alert state.
E. When stimuli are removed, the baby falls asleep.
ANS: B, C, E
Infant behavior is divided into sleep and awake states. REM sleep is accompanied by irregular respirations, visible REM activity under closed eyelids, and irregular sucking motions. Jerking movements may occur during crying as the infant discharges energy. When offending stimulation is removed, infants tend to fall back to sleep. Quiet motor activity occurs during the wide-awake state. Stimulation increases motor activity in the active alert state.

Cognitive Level: Comprehension/Understanding
Content Area: Pediatrics/Maternity
Patient Needs: Health Promotion and Maintenance
Integrated Process: Teaching/Learning
Difficulty: Difficult

PTS: 1

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