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 D
Explanation
he correct answer is choice D. Keep the infant well hydrated.This is because phototherapy can cause dehydration due to increased insensible water loss from the skin.Hydration helps the infant excrete bilirubin in urine and stool.
Choice A is wrong because elevating the head of the infant’s crib does not affect bilirubin levels or phototherapy effectiveness.
Choice B is wrong because applying a water-soluble ointment to the infant’s eyes can interfere with eye protection and cause eye irritation.The infant’s eyes should be covered with opaque patches or goggles during phototherapy to prevent eye damage.
Choice C is wrong because dressing the infant in a long-sleeved shirt reduces the amount of skin exposed to light and decreases the efficacy of phototherapy.The infant should be undressed except for a diaper and eye protection during phototherapy.
Normal ranges for bilirubin levels vary depending on the age of the infant, the type of jaundice, and the method of measurement.Generally, bilirubin levels above 25 mg/dL are considered dangerous and require urgent treatment.
Correct Answer is C
Explanation
The correct answer is choice C. Auscultate the fetal heart sounds.This is because spontaneous rupture of membranes (SROM) may be associated with fetal distress or cord prolapse, and the nurse should assess the fetal well-being as soon as possible.Fetal heart sounds can indicate the presence of fetal bradycardia, tachycardia, or decelerations, which may require immediate intervention.
Choice A is wrong because checking the specific gravity of the amniotic fluid is not a priority action after SROM.The specific gravity can help differentiate amniotic fluid from urine, but it is not as reliable as other methods such as nitrazine paper test or visual inspection.
Choice B is wrong because providing dry linens for the patient is a comfort measure, but not a priority action after SROM.The nurse should first ensure the safety of the fetus and the mother before attending to their comfort needs.
Choice D is wrong because notifying the health care provider is an important action after SROM, but not the first one.The nurse should gather relevant data such as fetal heart rate, maternal vital signs, and characteristics of the fluid before contacting the provider.
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