A nurse explains to new parents that their newborn has developed respiratory distress syndrome (RDS). Which of the following assessments that the nurse makes would support a diagnosis of RDS?
Select one:

Apical pulse of 148 beats per minute.

Respiratory rate of 40 during sleep.

Skin color jaundiced.

Chest retractions.

Answer and Explanation

The Correct Answer is D

Choice A Reason: Apical pulse of 148 beats per minute. This is not a finding that would support a diagnosis of RDS, but rather a normal finding for a newborn. A normal apical pulse for a newborn ranges from 120 to 160 beats per minute. A high pulse rate may indicate fever, infection, anemia, or dehydration. A low pulse rate may indicate hypothermia, hypoxia, or heart block.

Choice B Reason: Respiratory rate of 40 during sleep. This is not a finding that would support a diagnosis of RDS, but rather a normal finding for a newborn. A normal respiratory rate for a newborn ranges from 40 to 60 breaths per minute. A high respiratory rate may indicate respiratory distress, infection, or metabolic acidosis. A low respiratory rate may indicate respiratory depression, hypothermia, or narcotic exposure.

Choice C Reason: Skin color jaundiced. This is not a finding that would support a diagnosis of RDS, but rather a diﬀerent condition called jaundice. Jaundice is a yellowish discoloration of the skin and mucous membranes caused by elevated levels of bilirubin in the blood. Bilirubin is a breakdown product of hemoglobin that is normally excreted by the liver and kidneys. Jaundice can occur in newborns due to immature liver function, increased red blood cell breakdown, or blood group incompatibility. Jaundice does not aﬀect lung function or oxygenation.

Choice D Reason: Chest retractions. This is because chest retractions are a sign of respiratory distress that indicate increased work of breathing and reduced lung compliance. Chest retractions occur when the chest wall sinks in between the ribs or below the sternum during inhalation, creating a negative pressure that helps draw air into the lungs. RDS is a serious condition where the newborn's lungs are immature and lack sufficient surfactant, which is a substance that reduces surface tension and prevents alveolar collapse. RDS can cause respiratory distress, hypoxia, acidosis, and organ failure. It is more common in preterm infants, especially those born before 37 weeks' gestation.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A Reason: Two arteries, one vein. This is because two arteries and one vein are the normal components of the umbilical cord, which is a structure that connects the fetus to the placenta and provides blood circulation between them. The umbilical cord carries oxygenated blood from the placenta to the fetus through the umbilical vein, and deoxygenated blood from the fetus to the placenta through the umbilical arteries.

Choice B Reason: Two veins, one artery. This is an incorrect answer that indicates an abnormal anatomy of the umbilical cord, which is known as single umbilical artery (SUA). SUA is a condition where there is only one umbilical artery instead of two, which can reduce blood ﬂow and oxygen delivery to the fetus. SUA can be associated with congenital anomalies or growth restriction in some cases.

Choice C Reason: Two veins, two arteries. This is an incorrect answer that indicates an abnormal anatomy of the umbilical cord, which is known as double umbilical vein (DUV). DUV is a condition where there are two umbilical veins instead of one, which can increase blood ﬂow and oxygen delivery to the fetus. DUV can be associated with fetal overgrowth or polycythemia in some cases.

Choice D Reason: One artery, one vein. This is an incorrect answer that indicates an abnormal anatomy of the umbilical cord, which is also known as single umbilical artery (SUA). SUA is a condition where there is only one umbilical artery instead of two, which can reduce blood ﬂow and oxygen delivery to the fetus. SUA can be associated with congenital anomalies or growth restriction in some cases.

A. Respiratory rate of 16. B. Complaints by the client of feeling ﬂushed and warm. C. Fetal heart rate of 120. D. Patellar reﬂexes are absent.

Correct Answer is D

Explanation

Choice A Reason: Respiratory rate of 16. This is an incorrect answer that indicates a normal finding that does not suggest magnesium sulfate toxicity. Respiratory rate is a measure of the number of breaths per minute, which reﬂects the respiratory function and oxygenation status. Respiratory rate of 16 is within the normal range for adults, which is 12 to 20 breaths per minute. Respiratory rate of 16 does not indicate magnesium sulfate toxicity, which can cause respiratory rate below 12 breaths per minute.

Choice B Reason: Complaints by the client of feeling ﬂushed and warm. This is an incorrect answer that indicates a common side eﬀect that does not indicate magnesium sulfate toxicity. Feeling ﬂushed and warm are sensations that are caused by vasodilation (widening of blood vessels), which can occur as a result of magnesium sulfate administration. Feeling ﬂushed and warm are not signs of magnesium sulfate toxicity, but rather expected and mild reactions that usually subside within a few hours.

Choice C Reason: Fetal heart rate of 120. This is an incorrect answer that indicates a normal finding that does not suggest magnesium sulfate toxicity. Fetal heart rate is a measure of the number of beats per minute of the fetal heart, which reﬂects the fetal well-being and oxygenation status. Fetal heart rate of 120 is within the normal range for fetuses, which is 110 to 160 beats per minute. Fetal heart rate of 120 does not indicate magnesium sulfate toxicity, which can cause fetal heart rate below 110 beats per minute or above 160 beats per minute.

Choice D Reason: Patellar reﬂexes are absent. This is because absent patellar reﬂexes are a sign of magnesium sulfate toxicity, which is a condition where the level of magnesium in the blood is too high, which can cause adverse eﬀects on the neuromuscular and cardiovascular systems. Magnesium sulfate is a medication that is used to prevent or treat preterm labor, which is labor that occurs before 37 weeks of gestation. Magnesium sulfate works by relaxing the uterine muscles and inhibiting uterine contractions. However, magnesium sulfate can also aﬀect other muscles and nerves in the body, and cause symptoms such as muscle weakness, respiratory depression, hypotension, or cardiac arrest.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse explains to new parents that their newborn has developed respiratory distress syndrome (RDS). Which of the following assessments that the nurse makes would support a diagnosis of RDS? Select one:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Before applying a cord clamp, the nurse assesses the umbilical cord for vessels. The nurse expects to find: Select one:

Correct Answer is A

Explanation

A woman is being treated for preterm labor with magnesium sulfate. Which finding by the nurse indicates magnesium sulfate toxicity? Select one:

Correct Answer is D

Explanation

The nurse at a shelter is counseling a group of women experiencing domestic violence. What is most important for the nurse to emphasize? Select one:

A nurse explains to new parents that their newborn has developed respiratory distress syndrome (RDS). Which of the following assessments that the nurse makes would support a diagnosis of RDS? Select one:

Assessment of a pregnant woman reveals a pigmented vertical line between the umbilicus and the pubis. The nurse documents this finding as: Select one:

A client with insulin-dependent type 2 diabetes and an HbA1c of 6.0% is planning to become pregnant soon. What anticipatory teaching should the nurse provide this client? Select one:

The nurse, working in labor and delivery, performs a sterile vaginal exam on a laboring woman. During the exam, she feels a loop of pulsating cord in the vagina. The nurse would anticipate: Select one:

An nurse is counseling a new mother about the immunologic properties of breast milk. The nurse emphasizes that breast milk is the main source of which specific immunoglobulin? Select one:

In caring for the premature infant, the nurse must continually assess hydration status. Parameters to assess would include all of the following except: Select one:

Which of the following would the nurse expect to find in a newborn who is developing sepsis? Select one:

A nurse explains to new parents that their newborn has developed respiratory distress syndrome (RDS). Which of the following assessments that the nurse makes would support a diagnosis of RDS?
Select one: