A nurse is assessing a newborn 1 hour after birth. Which of the following respiratory rates is within the expected reference range for a newborn?

110/min

48/min

22/min

100/min

Answer and Explanation

The Correct Answer is B

a. 110/min - This respiratory rate is higher than the expected reference range for a newborn. Newborns typically have respiratory rates between 30 to 60 breaths per minute.

b. 48/min - This respiratory rate falls within the expected reference range for a newborn, which is typically between 30 to 60 breaths per minute.

c. 22/min - This respiratory rate is lower than the expected reference range for a newborn. Newborns typically have respiratory rates between 30 to 60 breaths per minute.

d. 100/min - While this respiratory rate is within the expected range, it's at the upper end of the range for a newborn. Typically, newborns have respiratory rates between 30 to 60 breaths per minute, so a rate of 100/min may be considered slightly elevated.

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Correct Answer is A

Explanation

- A: Plantar creases covering 2/3 of the sole is indicative of a more mature newborn, which is a significant finding in assessing gestational age.
- B: Acrocyanosis of hands and feet is a common finding in the first few days after birth and is not specifically related to gestational age.
- C: The condition of the anterior fontanel being soft and level is a normal finding and does not contribute to the assessment of gestational age.
- D: The presence of vernix caseosa in inguinal creases can be seen in both preterm and full-term newborns, thus it is not a specific indicator of gestational age.

A. Prepare for an exchange blood transfusion. B. Initiate early feeding. C. Suction excess mucus with a bulb syringe. D. Begin phototherapy.

Correct Answer is B

Explanation

A. Initiating early feeding helps promote the passage of meconium, which contains bilirubin, out of the newborn's body, reducing the risk of jaundice.

B. Preparing for an exchange blood transfusion is not appropriate for preventing jaundice at this stage. Exchange transfusion is a treatment option for severe hyperbilirubinemia that has not
responded to other measures.
C. Suctioning excess mucus with a bulb syringe is important for maintaining a patent airway in the newborn but does not directly prevent jaundice.
D. Beginning phototherapy is a treatment for jaundice once it has occurred but is not a preventive measure.

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A nurse is assessing a newborn 1 hour after birth. Which of the following respiratory rates is within the expected reference range for a newborn?

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Naxlex Comprehensive Predictor Exams

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