A nurse in the newborn nursery is caring for a group of newborns. Which of the following newborns requires immediate intervention?

A newborn who is 18 hr post-delivery and has acrocyanosis

A newborn who is 24-hr post-delivery and has not passed meconium

A newborn who is 24 hr post-delivery and has persistent tachycardia with a heart rate of 180 bpm

A newborn who is 24 hr post-delivery and has not voided

Answer and Explanation

The Correct Answer is C

A.   Acrocyanosis is a normal finding in newborns and does not require immediate intervention.
B.   Not passing meconium within the first 24 hours is not uncommon and may be normal.
C. Persistent tachycardia in a newborn, especially with a heart rate of 180 bpm, requires immediate intervention as it may indicate a cardiac or other medical issue.
D.   Not voiding within the first 24 hours may be normal, but it should be monitored.

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Correct Answer is C

Explanation

A. A hot pack to the perineum can be offered after 24 hours, but not before, as heat can increase bleeding.
B. A warm sitz bath can be offered after 24 hours, but not before, as heat can increase bleeding and infection risk.
C. The nurse should also apply an ice pack to the perineum for 20 minutes every 4 hours to reduce swelling and inflammation.
D. Providing a squeeze bottle of antiseptic solution is more related to perineal hygiene rather than pain relief.

A. Blot the perineal area dry after cleansing. B. Perform hand hygiene before and after voiding. C. Apply ice packs to the perineal area several times daily. D. Clean the perineal area from front to back. E. Wash the perineal area using a squeeze bottle of warm water after each voiding.

Correct Answer is ["A","B","D","E"]

Explanation

A. Blotting the perineal area dry helps prevent moisture retention, reducing the risk of infection.
B. Performing hand hygiene before and after voiding helps prevent the introduction of bacteria into the perineal area.
C. Applying ice packs may help reduce swelling but is not a routine measure for preventing infection.
D. Cleaning the perineal area from front to back helps prevent the introduction of fecal bacteria into the urethra and vagina.
E. Washing the perineal area using a squeeze bottle of warm water after each voiding helps maintain cleanliness and prevent infection.

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A nurse in the newborn nursery is caring for a group of newborns. Which of the following newborns requires immediate intervention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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