A nurse is assessing a newborn at 2 hours of life. Which of the following findings should the nurse report to the neonatologist?

Intracostal retractions

Caput succedaneum

Positive Babinski sign

Pink-tinged urine in the diaper

Answer and Explanation

The Correct Answer is A

A) Intracostal retractions:
Intracostal retractions indicate respiratory distress in the newborn and should be reported immediately to the neonatologist. Retractions occur when the muscles between the ribs (intercostal muscles) are drawn in with each breath, signifying increased effort to breathe. This could indicate a serious condition such as respiratory distress syndrome (RDS), pneumonia, or other respiratory compromise. This finding requires urgent assessment and potential intervention to ensure the neonate is receiving adequate oxygenation.

B) Caput succedaneum:
Caput succedaneum is a common and benign finding in newborns, especially after a vaginal delivery. It refers to a swelling of the soft tissue on the baby's head, often seen after prolonged labor or use of forceps during delivery. This condition is typically resolves on its own within a few days and does not require immediate intervention or reporting to the neonatologist.

C) Positive Babinski sign:
A positive Babinski sign (fanning of the toes when the sole is stroked) is a normal reflex in neonates and is expected up to about 2 years of age. It is part of the newborn's neurological development and indicates the functioning of the central nervous system. Therefore, this finding does not require reporting to the neonatologist.

D) Pink-tinged urine in the diaper:
Pink-tinged urine, also known as "brick dust" or uric acid crystals, is a common finding in the first few days of life. It is typically harmless and results from concentrated urine or from the breakdown of urates. It usually resolves as the newborn begins to consume more fluids and the urine becomes more diluted. This finding does not necessitate immediate reporting unless it persists or is associated with other symptoms.

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Correct Answer is A

Explanation

A) Mother Rh-, baby Rh+:
RhoGAM (Rh immune globulin) is administered to a mother who is Rh-negative and has delivered a baby who is Rh-positive. If the Rh-negative mother is exposed to Rh-positive blood (via the baby’s blood during delivery), her immune system may start producing antibodies against Rh-positive cells, which could affect future pregnancies. The RhoGAM injection works by preventing the mother from developing these antibodies, thereby protecting any subsequent pregnancies from hemolytic disease of the newborn (HDN) in which the mother’s antibodies attack the baby’s red blood cells. This is a crucial preventive measure to avoid sensitization to Rh-positive blood.

B) Mother Rh-, baby Rh-:
If both the mother and baby are Rh-negative, there is no concern about the development of antibodies because there is no exposure to Rh-positive blood. Therefore, RhoGAM is not necessary in this situation.

C) Mother Rh+, baby Rh+:
In this scenario, the mother is Rh-positive, so she cannot develop antibodies against Rh-positive blood, regardless of the baby's Rh status. Hence, RhoGAM is not required because there is no risk of Rh incompatibility.
D) Mother Rh+, baby Rh-:
Since the mother is Rh-positive, there is no risk of her immune system attacking an Rh-negative baby’s red blood cells. Thus, RhoGAM is not needed in this case either.

Correct Answer is ["4"]

Explanation

The Apgar score is calculated based on five criteria, each scored from 0 to 2:

Heart rate
- 0 = Absent
- 1 = Below 100 beats per minute ✅
- 2 = 100 or more beats per minute
Respiratory effort
- 0 = Absent
- 1 = Slow, irregular ✅
- 2 = Good, crying
Muscle tone
- 0 = Limp
- 1 = Some flexion of extremities ✅
- 2 = Active motion
Reflex irritability (response to stimulation, e.g., suctioning)
- 0 = No response
- 1 = Grimace ✅
- 2 = Crying, active withdrawal
Color
- 0 = Blue, pale
- 1 = Body pink, extremities blue
- 2 = Completely pink

Apgar Score Calculation:

Heart rate: 1
Respiratory effort: 1
Muscle tone: 1
Reflex irritability: 1
Color: 0

Total Apgar Score: 4

A score of 4 suggests the newborn is in distress and requires immediate medical intervention, such as oxygen support and further assessment.

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A nurse is assessing a newborn at 2 hours of life. Which of the following findings should the nurse report to the neonatologist?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Rho immune globulin (Rhogam) will be ordered postpartum if which situation occurs?

Correct Answer is A

Explanation

At 1 minute after birth the nurse assesses the newborn and notes the following: Heart rate: 80 beats/minute Respiratory effort: slow, irregular Muscle tone: some flexion of extremities Reflex irritability: grimacing Color: blue and pale The nurse would calculate an Apgar score of:

Correct Answer is ["4"]

Explanation

Apgar Score Calculation:

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