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
This means that the uterus is constantly contracted and does not relax between contractions.This can cause the placenta to separate from the uterine wall, which is called placental abruption or abruptio placentae.Placental abruption can deprive the baby of oxygen and nutrients and cause heavy bleeding in the mother.
Choice B is wrong because strong uterine contractions every 3-4 minutes are normal during labor and do not indicate placental abruption.
Choice C is wrong because bile-colored vomitus is not a sign of placental abruption, but rather a sign of hyperemesis gravidarum, a severe form of nausea and vomiting during pregnancy.
Choice D is wrong because fetal heart rate acceleration with fetal activity is a normal finding and indicates a healthy baby.Placental abruption can cause fetal distress and a decrease in fetal heart rate.
Correct Answer is C
Explanation
The correct answer is choice C. The woman’s temperature will increase when she is ovulating.This is because ovulation is triggered by a surge of luteinizing hormone (LH), which also causes a slight rise in basal body temperature (BBT).By measuring her BBT every morning before getting out of bed, the woman can detect this subtle change and identify her fertile window.
Choice A is wrong because ovulation typically occurs around 14 days before the next menstrual period, not seven days after the previous one.
The length of the menstrual cycle can vary from woman to woman, so counting days is not a reliable method of predicting ovulation.
Choice B is wrong because cervical mucus will appear clear, slippery and stretchy when the woman is ovulating, not tacky and cloudy.
This type of mucus helps sperm swim and survive in the reproductive tract.
The woman can check her cervical mucus by wiping with toilet paper or inserting a finger into her vagina.
Choice D is wrong because abdominal massage of the ovaries will not stimulate ovulation, and may even cause harm by injuring the delicate tissues or introducing infection.
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