A baby is grunting in the neonatal nursery. Which of the following actions by the nurse is appropriate?
Check the baby's diaper.
Place a pacifier in the baby's mouth.
Have the mother feed the baby.
Assess the respiratory rate.
The Correct Answer is D
Choice a) Check the baby's diaper is incorrect because this is not a priority action for a baby who is grunting in the neonatal nursery. Grunting is a sign of respiratory distress, which means that the baby is having difficulty breathing and is trying to keep air in the lungs by making a low-pitched sound with each expiration. Checking the baby's diaper may be part of routine care, but it does not address the underlying cause of the grunting or improve the baby's oxygenation. Therefore, this action should be done after assessing and treating the baby's respiratory status.
Choice b) Place a pacifier in the baby's mouth is incorrect because this is not an appropriate action for a baby who is grunting in the neonatal nursery. Grunting is a sign of respiratory distress, which means that the baby is having difficulty breathing and is trying to keep air in the lungs by making a low-pitched sound with each expiration. Placing a pacifier in the baby's mouth may interfere with the baby's breathing and worsen the grunting, as it can obstruct the airway, increase the work of breathing, or cause aspiration. Therefore, this action should be avoided or used with caution for babies who are grunting.
Choice c) Have the mother feed the baby is incorrect because this is not a safe action for a baby who is grunting in the neonatal nursery. Grunting is a sign of respiratory distress, which means that the baby is having difficulty breathing and is trying to keep air in the lungs by making a low-pitched sound with each expiration. Having the mother feed the baby may increase the risk of choking or aspiration, as the baby may not be able to coordinate sucking, swallowing, and breathing. Therefore, this action should be delayed or modified until the baby's respiratory status improves.
Choice d) Assess the respiratory rate is correct because this is the most important action for a baby who is grunting in the neonatal nursery. Grunting is a sign of respiratory distress, which means that the baby is having difficulty breathing and is trying to keep air in the lungs by making a low-pitched sound with each expiration. Assessing the respiratory rate can help to determine the severity and cause of the respiratory distress, as well as guide further interventions such as oxygen therapy, suctioning, or medication. The normal respiratory rate for a newborn ranges from 30 to 60 breaths per minute, and it may vary with sleep or activity. A respiratory rate above 60 breaths per minute or below 30 breaths per minute indicates abnormality and requires immediate attention. Therefore, this action should be done as soon as possible for babies who are grunting.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A: This is incorrect because both physiological and nonphysiological jaundice result from breakdown of erythrocytes. Jaundice is caused by the accumulation of bilirubin, a yellow pigment that is produced when red blood cells are destroyed. However, the rate and extent of hemolysis differ between the two types of jaundice.
Choice B: This is incorrect because kernicterus is a rare and serious complication of jaundice, not a usual outcome. Kernicterus occurs when bilirubin levels are very high and the pigment deposits in the brain, causing neurological damage. It can affect both physiological and nonphysiological jaundice, but it is more likely to occur in nonphysiological jaundice due to higher bilirubin levels and underlying conditions.
Choice C: This is incorrect because both physiological and nonphysiological jaundice begin at the head and progress down the body. This is because bilirubin accumulates in areas with high fat content, such as the skin, eyes, and brain. The distribution of jaundice depends on the level of bilirubin in the blood, not on the type of jaundice.
Choice D: This is the correct answer because nonphysiological jaundice appears in the first 24 hours of life, whereas physiological jaundice appears after the first 24 hours of life. Nonphysiological jaundice is caused by factors that increase hemolysis or impair bilirubin metabolism or excretion, such as blood group incompatibility, infection, liver disease, or enzyme deficiency. Physiological jaundice is caused by normal adaptation processes that occur after birth, such as increased red blood cell turnover, immature liver function, and delayed intestinal flora colonization.
Correct Answer is D
Explanation
Choice A: This is incorrect because lanugo is a fine, downy hair that covers the fetus in utero. It usually disappears by the 36th week of gestation, but it may persist in some preterm infants. Lanugo helps to retain body heat and protect the skin from amniotic fluid. Lanugo is not a sign of postmaturity, but of prematurity or intrauterine growth restriction.
Choice B: This is incorrect because a short, chubby appearance is typical of a term infant, who is born between 37 and 42 weeks of gestation. A term infant has a well-developed subcutaneous fat layer that gives them a rounded shape and smooth skin. A term infant also has a head circumference that is proportional to their body length and weight. A short, chubby appearance is not a sign of postmaturity, but of normal development.
Choice C: This is incorrect because vernix caseosa is a white, cheesy substance that covers the fetus in utero. It usually decreases by the 40th week of gestation, but it may remain in some term infants, especially in the skin folds. Vernix caseosa helps to moisturize and protect the skin from amniotic fluid and infection. Vernix caseosa is not a sign of postmaturity, but of term or near-term gestation.
Choice D: This is the correct answer because cracked, peeling skin is a common sign of postmaturity, which occurs when the infant is born after 42 weeks of gestation. A postmature infant has a loss of subcutaneous fat and water that results in dry, wrinkled, and desquamated skin. A postmature infant also has a large head circumference that is disproportionate to their body length and weight. Cracked, peeling skin indicates prolonged exposure to amniotic fluid and placental insufficiency.
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