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 C. Stretching your legs and pointing your toes toward your knee will bring relief from the leg cramps.This is because stretching can help relax the muscle and ease the spasm.
Choice A is wrong because elevating your legs may not help with leg cramps, and may actually worsen them by reducing blood flow to the muscles.
Choice B is wrong because massaging your legs may not be enough to relieve the cramps, and may also cause more pain if done too hard or too fast.
Choice D is wrong because putting a cold compress on the calf of your leg may not be effective for leg cramps, and may also cause more discomfort or inflammation.
Leg cramps are common during pregnancy, especially in the second and third trimester.They are caused by various factors, such as pregnancy weight gain, changes in blood circulation, pressure on the nerves and blood vessels, nutrient deficiency, lack of exercise, or fluid buildup in your legs.To prevent or reduce leg cramps, you should drink plenty of water, stay active, eat a balanced diet rich in calcium, magnesium, and potassium, avoid standing or sitting for long periods of time, wear comfortable shoes and socks, and sleep on your left side with a pillow under or between your legs.
If leg cramps persist or become severe, you should consult your healthcare provider for possible treatment options.
Correct Answer is A
Explanation
The correct answer is choice A. “Your labor may slow down if you receive an epidural now.” An epidural is a type of regional anesthesia that blocks pain in a specific area of the body.
It can be used to reduce pain during labor and delivery.
However, an epidural can also have some side effects, such as lowering blood pressure, causing fever, and slowing down labor progress.
Therefore, it is usually recommended to wait until the cervix is at least 4 to 5 cm dilated and the contractions are strong and regular before receiving an epidural.
Choice B is wrong because there is no fixed rule about how dilated the cervix needs to be before receiving an epidural.
Some women may receive an epidural earlier or later than others, depending on their pain level, medical history, and preferences.
Choice C is wrong because catheterization is not a prerequisite for receiving an epidural.
Catheterization is the insertion of a tube into the bladder to drain urine.
It may be done after receiving an epidural because the anesthesia can affect the ability to urinate.
However, it is not required before receiving an epidural.
Choice D is wrong because the station of the baby does not determine when a woman can have an epidural.
The station of the baby refers to how far the baby has descended into the pelvis.
It is measured in relation to the ischial spines, which are bony landmarks in the pelvis.
A positive station means that the baby is below the spines, while a negative station means that the baby is above the spines.
Zero station means that the baby is at the level of the spines.
The station of the baby does not affect the administration of an epidural, as long as there are no other complications or contraindications.
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