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

110/min

100/min

22/min

48/min

Answer and Explanation

The Correct Answer is D

A.   A respiratory rate of 110/min is too high for a newborn and may indicate respiratory distress.
B.   A respiratory rate of 100/min is too high for a newborn and may indicate respiratory distress.
C. A respiratory rate of 22/min is too low for a newborn.
D.   A normal respiratory rate for a newborn is between 40 and 60 breaths per minute.

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Correct Answer is A

Explanation

A. The presence of lochia rubra with small clots in the immediate postpartum period is expected. The firm and midline fundus indicates appropriate uterine contraction. Continued monitoring is appropriate.
B. Encouraging the client to empty her bladder is a valid intervention, but it is not the priority in this situation.
C. Increasing the frequency of fundal massage is unnecessary, as the fundus is already firm.
D. Notifying the provider is not necessary based on the described findings, as they are within the expected range.

A. A newborn who is 18 hr post-delivery and has acrocyanosis B. A newborn who is 24-hr post-delivery and has not passed meconium C. A newborn who is 24 hr post-delivery and has persistent tachycardia with a heart rate of 180 bpm D. A newborn who is 24 hr post-delivery and has not voided

Correct Answer is C

Explanation

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is 1 hr postpartum and observes a large amount of lochia rubra and several small clots on the client’s perineal pad. The fundus is midline and firm at the umbilicus. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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

Correct Answer is C

Explanation

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