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

Answer and Explanation

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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Correct Answer is C

Explanation

The correct answer is C. Observe for crowning.

A. Applying fundal pressure is not indicated when the fetal head is at 3+ station. Fundal pressure is generally discouraged as it can increase the risk of fetal and maternal complications.

B. Preparing to administer oxytocin may be necessary later in labor but is not the immediate priority when the fetal head is still at 3+ station.

C. Observing for crowning is the correct action.

Crowning occurs when the widest part of the fetal head is visible at the vaginal opening during contractions. It is a sign that the baby is descending and the client is in the second stage of labor.

D. Observing for the presence of a nuchal cord is a valid consideration, but observing for crowning takes precedence at this stage of labor. Nuchal cords can be managed appropriately once the fetal head has descended further.

A. Turn the client onto her left side. B. Massage the client's back. C. Encourage the client to rest between contractions D. Administer prescribed analgesic medication

Correct Answer is B

Explanation

The correct answer is B. Massage the client's back.

A. Turning the client onto her left side may be a comfort measure, but it is not specifically associated with the gate control theory of pain. It may help improve blood flow and relieve pressure but does not directly engage the gate control mechanism.

B. Massage the client's back is consistent with the gate control theory of pain.

According to the gate control theory, non-painful input (such as massage) can close the "gate" to painful input, reducing the perception of pain. Massage stimulates large-diameter nerve fibers, which can inhibit the transmission of painful signals.

C. Encouraging the client to rest between contractions is a general comfort measure but is not directly related to the gate control theory of pain.

D. Administering prescribed analgesic medication is a pharmacological approach to pain management and is not specifically associated with the gate control theory. Medications can act on pain receptors but do not engage the gate control mechanism.

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A nurse is assessing a newborn who is 12 hr old. Which of the following manifestations requires intervention by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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