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 A
Explanation
The correct answer is choice A. The client is trying to reassure herself concerning the present situation.This is a common coping strategy for women who face the risk of preterm labor and delivery.The client may be experiencing fear, anxiety, or denial about the possible outcomes of her pregnancy.
Choice B is wrong because coping as expected in this situation implies that there is a normal or standard way of coping with preterm labor, which is not true.Different women may cope differently depending on their personal, social, and emotional factors.
Choice C is wrong because anxious to see the new baby does not reflect the client’s statement.
The client is not expressing excitement or eagerness about the birth, but rather a rationalization that everything will be okay despite the risks.
Choice D is wrong because able to use previously learned knowledge in a new situation does not apply to the client’s statement.
The client is not using her sister’s experience as a source of information or guidance, but rather as a way of minimizing or dismissing her own situation.
Correct Answer is C
Explanation
The correct answer is choice C. “What drugs have you used during your pregnancy?”.
This question is open-ended and nonjudgmental, which encourages the patient to disclose more information about her drug use.
The nurse can then assess the type, frequency, and amount of drugs used and plan appropriate interventions.
Choice A is wrong because it is a closed-ended question that can be answered with a yes or no, and it implies criticism of the patient’s behavior, which may make her defensive and less willing to cooperate.
Choice B is wrong because it is also a closed-ended question that can be answered with a yes or no, and it may frighten or anger the patient, who may not be aware of the legal implications of her drug use.
Choice D is wrong because it is too vague and may not cover all the possible drugs that the patient may have used, such as prescription medications, alcohol, or tobacco.
It also labels the patient as a drug user, which may offend her or make her feel ashamed.
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