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 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.

A. “Did you know that your baby’s development is affected by the type of drugs you use during the pregnancy?”. B. “Are you aware that using nonprescription medication during pregnancy may be regarded as child abuse?”. C. “What drugs have you used during your pregnancy?”. D. “Have you ever used street drugs?”.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

The nurse suspects drug abuse in a patient admitted with no prenatal care and a diagnosis of abruptio placentae.Which question would elicit the most information from the patient concerning the suspected drug use?

Correct Answer is C

Explanation

The physician prescribes prostaglandin (PGE2) gel for a patient being admitted for induction of labor. Which finding would best indicate that the prostaglandin gel is effective?

A patient has been instructed to increase the protein in her diet. Which statement by the patient shows a need for further instruction?

A client in preterm labor is managed with terbutaline. Which will a nurse need to consider in planning care for this client?

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A nurse is caring for a patient who is receiving oxytocin injection intravenously for labor induction.The nurse should monitor this patient for which adverse effect of oxytocin?

The mother of a 4-hour-old newborn reports to a nurse, “My son is producing breast milk.” The nurse’s response should be based on which understanding about newborn physiology? This is:.

A client who is two weeks postpartum calls the office and tells a nurse, "l am having a small amount of brownish discharge from my vagina." Which response is appropriate for the nurse to make?

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