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) Assess the woman's fundus and massage it if boggy:
A saturated pad within 15 minutes after delivery suggests a hemorrhage, and the first priority in this situation is to assess the fundus. If the fundus is boggy (soft and not contracted), it is a sign of uterine atony, which is the most common cause of postpartum hemorrhage. Massaging the fundus helps stimulate uterine contraction, which can help stop the bleeding.

B) Assess the woman's pulse and BP for signs of hypovolemic shock:
While it is important to monitor vital signs for signs of hypovolemic shock (e.g., increased heart rate, decreased blood pressure, and pale skin), this action would not be the first priority in managing a postpartum hemorrhage. The immediate focus should be on stopping the bleeding by addressing uterine atony. Hypovolemic shock assessment is important, but it comes after the initial steps of managing hemorrhage.

C) Call the woman's primary healthcare provider:
Calling the provider may be necessary if the bleeding does not stop after initial interventions. However, it should not be the first action. The nurse should first assess the uterus and attempt to stop the bleeding by massaging the fundus before calling the provider.

D) Begin an IV infusion of Ringer's lactate solution and administer oxytocin:
Starting an IV infusion and administering oxytocin may be part of the treatment for postpartum hemorrhage, but the first action should be to assess and manage the fundus. Oxytocin can help contract the uterus, but massaging the fundus is the immediate intervention. Intravenous fluids and medications should be initiated once the uterus is assessed and massaged, especially if bleeding persists.

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?

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Naxlex Comprehensive Predictor Exams

While assessing a patient who gave birth 5 hours ago, the nurse finds that the woman has completely saturated: pad within 15 minutes. What is the nurse's first action?

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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