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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

The correct answer is choice D. Apply petrolatum to the patient’s perineum.This is because petrolatum can help soothe and protect the perineal area, which may be swollen, bruised, or have stitches after a vaginal delivery.Applying petrolatum can also prevent the pad from sticking to the wound and causing more pain.

Choice A is wrong because observing the patient for vaginal discharge of bright red blood is not a specific action for perineal care.Bright red blood may indicate postpartum hemorrhage, which requires immediate medical attention.

Choice B is wrong because assessing the patient’s vaginal tone is not a priority action for perineal care.Vaginal tone may be reduced after childbirth due to stretching of the pelvic floor muscles, but this can improve with time and exercises.

Choice C is wrong because massaging the patient’s perineum is not recommended for perineal care.Massaging the perineum may cause more trauma and discomfort to the area, especially if there are stitches or hemorrhoids.Massaging the fundus (the top of the uterus) may be done to help it contract and prevent bleeding, but this is different from massaging the perineum.

A. Trying to reassure herself concerning the present situation. B. Coping as expected in this situation. C. Anxious to see the new baby. D. Able to use previously learned knowledge in a new situation.

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.

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A nurse is assessing a newborn. Which finding may indicate a problem?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

During the postpartal admission assessment, the nurse notes that a patient’s perineum appears edematous and ecchymotic. Based on this finding, which action should the nurse take?

Correct Answer is D

Explanation

A client in preterm labor tells the nurse, “It’s okay that I am in labor.I’m not worried. My sister’s baby was born this early, and he is doing great.” How should the nurse interpret this statement by the client? The client is:.

Correct Answer is A

Explanation

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A nurse is assessing a newborn.
Which finding may indicate a problem?