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 B
Explanation
The American Academy of Pediatrics (AAP) strongly recommends exclusive breastfeeding for at least 6 months.
Exclusive breastfeeding means that your baby has only breastmilk for 6 months. That means giving your baby breastmilk from your breasts or from botles.
Don’t give your baby water, sugar water, or formula.
The other choices are not recommended:
A. Newborns do not need water between feedings.
C. The length of time a newborn feeds per breast can vary and is not necessarily
limited to 5-10 minutes.
D. Newborns typically have more than two to four wet diapers every 24 hours.
Correct Answer is B
Explanation
A newborn who was exposed to cocaine in utero may exhibit a high-pitched cry as well as other symptoms such as irritability, tremors, and feeding difficulties.
Choice A is not an answer because hypotonicity is not a common finding in newborns exposed to cocaine in utero.
Choice C is not an answer because increased head circumference is not a common finding in newborns exposed to cocaine in utero.
Choice D is not an answer because decreased startle response is not a common finding in newborns exposed to cocaine in utero.
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