A nurse has received a mother and her baby in the postpartum unit. The baby is approximately 2 hours old.
Which of the following is NOT a symptom of transient tachypnea of the newborn?
Heart rate of 170
Grunting or sighing with respirations
Nasal flaring
Respirations of 72
The Correct Answer is A
Choice A rationale
Heart rate of 170. A heart rate of 170 is not a symptom of transient tachypnea of the newborn.
Choice B rationale
Grunting or sighing with respirations. This is a symptom of transient tachypnea of the newborn.
Choice C rationale
Nasal flaring. This is a symptom of transient tachypnea of the newborn.
Choice D rationale
Respirations of 72. This is a symptom of transient tachypnea of the newborn.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Chadwick’s sign is a bluish discoloration of the cervix, vagina, and labia resulting from increased blood flow. This sign is commonly seen in early pregnancy, but it does not indicate the presence of blood in the peritoneum.
Choice B rationale
Chvostek’s sign is a clinical sign of existing nerve hyperexcitability seen in hypocalcemia. It refers to an abnormal reaction to the stimulation of the facial nerve. This sign is not related to a ruptured ectopic pregnancy.
Choice C rationale
Goodell’s sign is a significant softening of the vaginal portion of the cervix from increased vascularization. This vascular softening is seen in early pregnancy. It does not indicate the presence of blood in the peritoneum.
Choice D rationale
Cullen’s sign is the appearance of bruising in the skin around the umbilicus. It occurs when there is blood in the peritoneum, or intra-abdominal bleeding. In the case of a suspected ruptured ectopic pregnancy, Cullen’s sign would indicate the presence of blood in the peritoneum.
Correct Answer is D
Explanation
The correct answer is choiced. Slightly above the umbilicus.
Choice A rationale:
At 22 weeks of gestation, the fundus is not typically 5 cm above the umbilicus. This measurement would be more consistent with a later stage of pregnancy, around 28 weeks.
Choice B rationale:
The fundus being slightly below the umbilicus is more consistent with an earlier stage of pregnancy, around 20 weeks. At 22 weeks, the fundus should be higher.
Choice C rationale:
The fundus being 3 cm below the umbilicus is also indicative of an earlier stage of pregnancy, not 22 weeks. This would be expected around 18-20 weeks.
Choice D rationale:
At 22 weeks of gestation, the fundus is typically located slightly above the umbilicus.This corresponds with the general rule that the fundal height in centimeters should match the number of weeks of pregnancy, give or take 2 cm.
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