A nurse is assessing a newborn.
Which finding may indicate a problem?
The newborn’s nostrils flare slightly during respiration.
The newborn’s hands and feet are blue and feel cool.
The newborn’s eyes move randomly when his head is turned to the side.
The newborn’s tongue thrusts forward when it is lightly touched.
The Correct Answer is A
The correct answer is choice A. The newborn’s nostrils flare slightly during respiration. This is a sign of respiratory distress in a newborn.
Flaring nostrils indicate that the newborn is working hard to breathe and may not be getting enough oxygen.
Choice B is wrong because the newborn’s hands and feet are blue and feel cool. This is a normal finding called acrocyanosis, which occurs due to immature peripheral circulation.
It usually resolves within 24 to 48 hours after birth.
Choice C is wrong because the newborn’s eyes move randomly when his head is turned to the side. This is a normal finding called nystagmus, which occurs due to immature eye muscles and coordination.
It usually disappears by 6 months of age.
Choice D is wrong because the newborn’s tongue thrusts forward when it is lightly touched. This is a normal finding called the extrusion reflex, which helps the newborn to suck and swallow.
It usually fades by 4 months of age.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Answer and explanation..
The correct answer is choice C. Jitteriness.Jitteriness is a sign of low blood sugar (hypoglycemia) which is common in infants of diabetic mothers (IDM) because they have high levels of insulin in their blood that lower their glucose levels after birth.Hypoglycemia can also cause other symptoms such as seizures, lethargy, poor feeding, sweating, trembling, and pale complexion.
Choice A is wrong because abdominal distention is not a typical symptom of IDM.
It can be caused by other conditions such as intestinal obstruction or infection.
Choice B is wrong because high-pitched cry is not a specific symptom of IDM.
It can be caused by many factors such as pain, hunger, or neurological problems.
Choice D is wrong because excessive drooling is not a common symptom of IDM.
It can be a sign of oral problems such as teething or infection.
Normal ranges for blood glucose in newborns are 40 to 150 mg/dL (2.2 to 8.3 mmol/L).
IDM should be monitored closely for hypoglycemia and treated promptly with glucose if needed.
Correct Answer is A
Explanation
Choice A reason:
At 37 weeks, especially in gestational diabetes, fetal lungs may still be immature. Amniocentesis checks lung maturity to ensure the baby can breathe effectively if early delivery is needed due to fetal compromise.
Choice B reason:
Fetal renal function is not typically assessed through amniocentesis at term. Kidney function is monitored via ultrasound, not by analyzing amniotic fluid at 37 weeks.
Choice C reason:
Amniotic fluid glucose levels are not used to manage gestational diabetes. Maternal blood glucose is the standard for monitoring and treatment.
Choice D reason:
Congenital anomalies are usually detected earlier in pregnancy. By 37 weeks, the focus of amniocentesis is on delivery planning, not anomaly detection.
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