A nurse in a newborn nursery is receiving change-of-shift report for four newborns.
Which of the following newborns should the nurse assess first?
A newborn who is 24 hr old and has not had a meconium stool.
A newborn who has a short frenulum and is having difficulty breastfeeding.
A newborn who is 10 hr old and has onset tachypnea.
A newborn who is 30 hr old and has blood-tinged discharge in her diaper.
The Correct Answer is C
A newborn who is 10 hr old and has onset tachypnea.
Tachypnea means rapid breathing and can be a sign of respiratory distress.
Transient tachypnea of the newborn (TTN) is a respiratory disorder usually seen shortly after delivery in babies who are born near or at term.
It is important for the nurse to assess this newborn first to determine the cause of the tachypnea and provide appropriate care.
Choice A, a newborn who is 24 hr old and has not had a meconium stool, may
require further assessment but is not as urgent as a newborn with tachypnea.
Choice B, a newborn who has a short frenulum and is having difficulty breastfeeding, may require assistance with feeding but is not as urgent as a newborn with tachypnea.
Choice D, a newborn who is 30 hr old and has blood-tinged discharge in her diaper, may have pseudomenstruation which is normal and not a cause for concern.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Do not retract the foreskin to clean your baby’s penis during each diaper change.
The foreskin should not be retracted for cleaning during infancy.
Choice A is incorrect because you should clean around the umbilical cord stump with plain water and blot dry until it falls off naturally.
Choice B is incorrect because swaddling a baby tightly with their legs extended is not recommended.
Choice C is incorrect because a newborn should urinate at least six times a day.
Correct Answer is A
Explanation
A nuchal cord occurs when the umbilical cord wraps around the fetal neck completely or for 360 degrees.
In some cases, a tight nuchal cord can cause conjunctival hemorrhage and petechiae.
Choice B) is not correct because erythema toxicum is a common rash seen in newborns and is not related to a nuchal cord.
Choice C) is not correct because periauricular papillomas are benign skin growths near the ear and are not related to a nuchal cord.
Choice D) is not correct because telangiectatic nevi, also known as stork bites or salmon patches, are common birthmarks seen in newborns and are not related to a nuchal cord.
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