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 A

Explanation

A. Correct. In rapidly progressing labor, applying gentle perineal pressure helps control the speed of delivery and can prevent or minimize perineal tearing or lacerations. It also helps to manage the delivery of the fetal head, especially in cases where the labor is very rapid which can cause neurologic damage (increased intracranial pressure and dural/subdural tearing).

B. Cutting the umbilical cord is not the priority in this situation. The focus should be on the immediate management of the delivery process and preventing complications related to perineal tearing.

C. Preventing the perineum from tearing: While preventing the perineum from tearing is important, it is not the immediate priority in the context of rapidly progressing labor. The primary focus should be on safely delivering the baby, which involves controlling the delivery of the fetal head to prevent complications.

D. Promoting the delivery of the placenta is a consideration for the third stage of labor, which follows the delivery of the baby. It is not the priority during the active phase of delivery.

A. "This medication will stop your labor" B. "This medication stimulates fetal lung maturity" C. "This medication will decrease your risk for uterine infections" D. "This medication will increase your baby's weight"

Correct Answer is B

Explanation

A. "This medication will stop your labor": Betamethasone is not intended to stop labor. It is given to promote fetal lung maturity and reduce the risk of complications associated with preterm birth.

B. "This medication stimulates fetal lung maturity": This is the correct statement. Betamethasone is administered to enhance the production of surfactant in the fetal lungs, improving respiratory outcomes for the preterm infant.

C. "This medication will decrease your risk for uterine infections": Betamethasone does not directly decrease the risk of uterine infections. Its primary benefit is in promoting fetal lung maturity.

D. "This medication will increase your baby's weight": Betamethasone is not given to increase the baby's weight. Its main focus is on improving lung function and reducing respiratory complications in preterm infants.

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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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Correct Answer is A

Explanation

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Correct Answer is B

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