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 A

Explanation

A. The priority is to assess the client's uterine fundus to determine if it is well-contracted. Excessive bleeding could be indicative of uterine atony, and prompt assessment is crucial for intervention.
B. Assisting the client on a bedpan to urinate is a secondary intervention. While a distended bladder can contribute to uterine atony, assessing the fundus comes first to determine the cause.
C. Increasing fluid intake is important for postpartum recovery, but it is not the immediate priority in this situation.
D. Preparing to administer oxytocic medication may be necessary if uterine atony is identified during the fundal assessment. However, assessing the fundus comes first to guide appropriate interventions.

A. Respiratory distress B. Acrocyanosis. C. Accidental lacerations D. Hypothermia

Correct Answer is A

Explanation

A. Assessing for respiratory distress is the priority as the newborn's ability to breathe independently is crucial immediately after birth.
B. Acrocyanosis is a common and expected finding in newborns, especially in the first few hours after birth.
C. Accidental lacerations, while important to assess, are not as immediately critical as respiratory distress.
D. While hypothermia is a concern, addressing respiratory distress takes precedence in the immediate postoperative period.

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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?

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Naxlex Comprehensive Predictor Exams

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