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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. The uterine fundus is expected to be at the level of the umbilicus after delivery and descends approximately one fingerbreadth (or 1 cm) per day after delivery.
B. The uterine fundus would be too high for this time frame.
C. The fundus should reach the level of the symphysis pubis by 10 days postpartum.
D. The uterine fundus should not be palpated to the right of the umbilicus; it should be midline or slightly to the right. A lateral displacement of the fundus may indicate a full bladder, which can interfere with uterine contraction and increase the risk of bleeding.
Correct Answer is C
Explanation
A. Turning the newborn on his side may be done after suctioning but is not the initial priority.
B. Using a suction catheter with low negative pressure may be appropriate, but a bulb syringe is commonly used for newborns.
C.Suctioning the mouth is a necessary step to ensure effective breathing.
D. Suctioningthe nose first may cause the infant to gasp and potentially draw the secretions present in the mouth into the airway, which could lead to aspiration.
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