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

The correct answer is A. Monitor the fetal heart rate (FHR) every hour.

A. Monitoring the fetal heart rate every hour is a crucial aspect of the plan of care during active labor. Continuous fetal monitoring helps assess the well-being of the baby and ensures timely identification of any signs of fetal distress.

B. Inserting an indwelling urinary catheter is not a routine intervention during active labor. The bladder can be monitored using other non-invasive methods, and catheterization is generally reserved for specific indications.

C. Keeping four side rails up while the client is in bed is not recommended. It may limit the client's mobility and is not a standard practice during labor. Ensuring the safety of the client and promoting mobility is important.

D. Checking the cervix prior to analgesic administration may be necessary, but it is not a general action for every client in active labor. The need for cervical checks should be individualized based on the client's progress, preferences, and clinical indications.

A. Fetal lie is longitudinal. B. Fetal position is persistent occiput posterior. C. Fetal attitude is in general flexion. D. Material pelvis is gynecoid

Correct Answer is B

Explanation

A. Fetal lie being longitudinal is a normal and common fetal lie. It refers to the long axis of the fetus being parallel to the long axis of the mother.

B. Fetal position being persistent occiput posterior is a potential contributing cause.

Occiput posterior position (OP) can result in a more challenging and prolonged labor. This position, where the back of the baby's head is facing the mother's spine, is associated with increased back pain during labor.

C. Fetal attitude in general flexion is a favorable presentation for labor. Flexion allows for a smaller presenting diameter of the fetal head, facilitating descent through the birth canal.

D. Maternal pelvis being gynecoid is a favorable pelvic type for childbirth. The gynecoid pelvis is typically associated with easier labor and delivery.

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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?

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