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 B

Explanation

Choice A Reason: "If I try to talk to my partner during a contraction, I can't." This is an incorrect answer that indicates a sign of true labor, not false labor. True labor is a condition where there are regular and painful uterine contractions that cause cervical dilation and eﬀacement, and lead to delivery of the baby and placenta. True labor contractions are usually strong and consistent, and they tend to increase or persist with activity or position changes. True labor contractions can be so intense that they interfere with speech or breathing.

Choice B Reason: ) "My contractions slow down when I walk around." This is because this statement by the client would lead the nurse to suspect that the woman is experiencing false labor, which is also known as Braxton Hicks contractions or practice contractions. False labor is a condition where there are irregular and painless uterine contractions that do not cause cervical dilation or eﬀacement. False labor can occur throughout pregnancy, but it becomes more noticeable and frequent in late pregnancy. False labor contractions are usually weak and inconsistent, and they tend to decrease or stop with activity or position changes.

Choice C Reason: "I feel contractions start mostly in my back and they sweep around to the top of my abdomen." This is an incorrect answer that indicates a sign of true labor, not false labor. True labor contractions usually start in the lower back and radiate to the lower abdomen or groin, following a wave-like patern. False labor contractions are more likely to be felt in the upper abdomen or sides, without a clear patern.

Choice D Reason: "My contractions are about 6 minutes apart and regular." This is an incorrect answer that indicates a sign of true labor, not false labor. True labor contractions usually have a regular frequency and duration, and they become closer and longer as labor progresses. False labor contractions are more likely to have an irregular frequency and duration, and they do not change significantly over time.

A. Retained placental fragments. B. Cervical or vaginal lacerations. C. Uterine inversion. D. Uterine atony.

Correct Answer is D

Explanation

Choice A Reason: Retained placental fragments. This is an incorrect answer that refers to a diﬀerent cause of late postpartum hemorrhage, which is less common than uterine atony. Retained placental fragments are pieces of placenta that remain atached to the uterine wall after delivery, which prevent uterine contraction and involution, and provide a source of bleeding and infection. Retained placental fragments can be caused by abnormal placentation (such as placenta accreta), manual removal of placenta, or incomplete separation of placenta.

Choice B Reason: Cervical or vaginal lacerations. This is an incorrect answer that refers to a diﬀerent cause of late postpartum hemorrhage, which is more likely to cause early postpartum hemorrhage than late postpartum hemorrhage. Cervical or vaginal lacerations are tears or cuts in the cervix or vagina that occur during delivery, which can cause bleeding from the damaged blood vessels. Cervical or vaginal lacerations can be caused by rapid or instrumental delivery, large or malpositioned fetus, or episiotomy.

Choice C Reason: Uterine inversion. This is an incorrect answer that refers to a diﬀerent cause of late postpartum hemorrhage, which is rare and life-threatening. Uterine inversion is a condition where the uterus turns inside out and protrudes through the cervix and vagina after delivery, which can cause massive bleeding and shock. Uterine inversion can be caused by excessive traction on the umbilical cord, fundal pressure, or uterine relaxation.

Choice D Reason: Uterine atony. This is because uterine atony is a condition where the uterus fails to contract and retract after delivery, which leads to bleeding from the placental site. Uterine atony is the most common cause of late postpartum hemorrhage, accounting for about 75% of cases. Late postpartum hemorrhage is excessive bleeding from the uterus or genital tract that occurs more than 24 hours but less than 12 weeks after delivery. Late postpartum hemorrhage can be caused by retained placental fragments, subinvolution of the uterus, infection, or coagulation disorders.

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

A woman in her 40th week of pregnancy calls the nurse at the clinic and says she's not sure whether she is in true or false labor. Which statement by the client would lead the nurse to suspect that the woman is experiencing false labor? Select one:

Correct Answer is B

Explanation

When reviewing the causes of late postpartum hemorrhage, which of the following would the nurse identify as the most common cause? Select one:

Correct Answer is D

Explanation

A client who is breastfeeding her newborn tells the nurse, "I notice that when I feed him, I feel fairly strong contraction-like pain. Labor is over. Why am I having contractions now?" Which response by the nurse would be most appropriate? Select one:

Parents have been told their child has fetal alcohol syndrome (FAS). Which statement by a parent indicates that additional teaching is required? Select one:

The Mother-Baby nurse is caring for a two hour old newborn who is 36 4/7 weeks gestation. The nurse assesses that the newborn is experiencing tremors (jiteriness). What nursing action has the highest priority? Select one:

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

The client at 42 weeks' pregnancy is admited for induction of her labor. Which statement indicates that she understands the Reasons for the induction? 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: