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 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.

A. “This is a cephalhematoma, which can occur spontaneously.” B. “Caput succedaneum occurs due to compression of blood vessels.” C. “This is erythema toxicum, which is a transient condition.” D. “Mongolian spots can be found on the skin of many newborns.”

Correct Answer is B

Explanation

A. A cephalhematoma is a collection of blood under the periosteum that does not cross the suture lines and can take weeks to resolve.
B. Caput succedaneum occurs due to compression of blood vessels during delivery, resulting in edema and bruising of the scalp. It crosses the suture lines and usually resolves within a few days and does not cause any complications.
C. Erythema toxicum is a rash that is unrelated to head swelling.
D. Mongolian spots are blue-gray patches on the skin, not associated with head swelling.

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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 has just delivered a newborn. The nurse notes secretions bubbling out of the newborn’s nose and mouth. Which of the following actions is the nurse’s priority?

Correct Answer is C

Explanation

A nurse is caring for a newborn delivered by vaginal birth with a vacuum assist. The newborn’s mother asks about the swollen area on her son’s head. After palpation to identify that the swelling crosses the suture line, which of the following is an appropriate response by the nurse?

Correct Answer is B

Explanation

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