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. Maintaining the infants’ airways is the nurse’s priority when caring for a set of twins delivered by cesarean delivery.This is because twins are more likely to be born early and need special care after birth than single babies.They may have breathing difficulties or low oxygen levels and require oxygen therapy or ventilation.
The nurse should assess the infants’ respiratory status and intervene as needed.
Choice B is wrong because keeping the infants in a warm, draft-free environment is important but not as urgent as ensuring their airways are clear and they are breathing well.Premature twins may have trouble regulating their body temperature and need to be kept warm, but this can be done after their airways are secured.
Choice C is wrong because placing identification bands on the infants is a standard procedure but not a priority.
The nurse should make sure the infants are correctly identified and matched with their mother, but this can be done after their vital signs are stable.
Choice D is wrong because monitoring the infants’ vital signs is also important but not as urgent as maintaining their airways.
The nurse should check the infants’ heart rate, blood pressure, temperature and blood sugar levels regularly, but this can be done after their respiratory status is assessed and managed.
Normal ranges for vital signs in newborns are:
• Heart rate: 100 to 160 beats per minute
• Blood pressure: 50 to 75 mm Hg systolic and 30 to 45 mm Hg diastolic
• Temperature: 36.5 to 37.5°C (97.7 to 99.5°F)
• Blood sugar: 40 to 80 mg/dL
Correct Answer is A
Explanation
The correct answer is choice A and it indicates fetal distress because it is a sign oflate deceleration.Late decelerations are due touteroplacental insufficiencyas the result of decreased blood flow and oxygen to the fetus during the uterine contractions.This causeshypoxemiaand can lead to fetal acidosis and neurological damage.
Choice B is wrong because it indicates anormal variabilityin the fetal heart rate, which reflects a healthy autonomic nervous system.A normal fetal heart rate is 120-160 beats per minute.
Choice C is wrong because it indicates anearly accelerationin the fetal heart rate, which is a benign finding that may occur with fetal movement or stimulation.
Choice D is wrong because it indicates anearly decelerationin the fetal heart rate, which is a normal response to fetal head compression during contractions.
It does not indicate fetal distress.
Normal ranges for fetal heart rate patterns are:
• Baseline: 120-160 beats per minute
• Variability: 6-25 beats per minute
• Accelerations: at least 15 beats per minute above baseline for at least 15 seconds
• Decelerations: none or early (mirror contractions)
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