A nurse is assessing a newborn who is 12 hr old. Which of the following manifestations requires intervention by the nurse?
Acrocyanosis of the extremities
Murmur at the left sternal border
Substernal chest retractions while sleeping
Positive Babinski reflex
The Correct Answer is C
The correct answer is C.
A. Acrocyanosis of the extremities: Acrocyanosis, or blueness of the extremities, is a common finding in newborns and is usually considered normal. It often resolves on its own and doesn't typically require intervention.
B. Murmur at the left sternal border: It's not uncommon for newborns to have innocent murmurs, and many resolve on their own as the infant grows. A murmur at the left sternal border alone may not necessarily indicate a problem, but it should be assessed by a healthcare provider.
C. Substernal chest retractions while sleeping: Chest retractions can be a sign of respiratory distress, and intervention is needed to assess and address the cause. Substernal retractions suggest increased work of breathing and may indicate a respiratory issue that requires attention.
D. Positive Babinski reflex: The Babinski reflex is a normal neurological response in infants. It involves the toes fanning out when the sole of the foot is stroked. A positive Babinski reflex is expected in a 12-hour-old newborn and does not require intervention.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is A. Jitteriness.
A. Jitteriness: Jitteriness is a common manifestation of hypoglycemia in newborns. It is a tremulous movement that can be observed in response to low blood glucose levels.
B. Hypertonia: Hypertonia, or increased muscle tone, is not a typical manifestation of hypoglycemia in newborns. Instead, hypoglycemia is more likely to be associated with hypotonia or limpness.
C. Abdominal distention: Abdominal distention is not a typical sign of hypoglycemia in newborns. It may be associated with other conditions, such as gastrointestinal issues, but it is not directly related to low blood glucose levels.
D. Mottling: Mottling refers to a blotchy or uneven skin color and is not a specific sign of hypoglycemia. It can be associated with various conditions, including poor circulation, but it is not a primary indicator of low blood glucose.
Correct Answer is A
Explanation
The correct answer is A. Two arteries and one vein.
A. Two arteries and one vein is the typical composition of the umbilical cord vessels. The umbilical arteries carry deoxygenated blood and waste products away from the fetus, while the umbilical vein carries oxygenated blood and nutrients to the fetus.
B. Two veins and one artery is not the usual configuration of the umbilical cord vessels. The presence of two veins is atypical.
C. One artery and one vein is an abnormal finding and may be associated with certain congenital anomalies or fetal abnormalities. This configuration is not the norm.
D. Two arteries and two veins is not a standard or physiological composition of the umbilical cord. The typical configuration is two arteries and one vein.
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