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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
The largest fetal diameter passing through the pelvic outlet is not what is indicated by the presenting part being at 0 station. This would be more indicative of a positive station, such as
+31.
Choice B rationale
The position of the fetal head, such as left occiput posterior, is not determined by the station of the presenting part. The station refers to the level of the presenting part in relation to the mother’s ischial spines.
Choice C rationale
The palpability of the posterior fontanel is not related to the station of the presenting part. The fontanels are soft spots on the baby’s head which allow for compression during birth and brain growth after birth.
Choice D rationale
This is the correct interpretation of the clinical finding. The presenting part is at 0 station when its lowermost portion is at the level of an imaginary line drawn between the client’s ischial spines.
Correct Answer is A
Explanation
Potential Condition: Preterm labor. Based on the information provided, the patient is most likely experiencing preterm labor. Actions to Take: Administer tocolytics. If the patient is in preterm labor, the nurse should administer tocolytics to try to stop the contractions. Parameters to Monitor: Frequency of contractions. The nurse should monitor the frequency of contractions to assess the patient’s progress.
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