A nurse is assessing a newborn who was born 2 hr ago and was admitted to the neonatal intensive care unit with chest wall retractions and blue discoloration of the hands and feet. Which of the following findings indicates a decline in the newborn's status?
Apneic episode less than 15 seconds
Fine crackles
Oxygen saturation of 89%
Nasal flaring
The Correct Answer is C
Rationale:
A. An apneic episode less than 15 seconds may be considered within normal limits for a newborn and does not necessarily indicate a decline in status.
B. Fine crackles may indicate fluid in the lungs but are not specific to a decline in the newborn's status.
C. An oxygen saturation of 89% indicates hypoxemia, which is a significant concern and suggests respiratory compromise. It indicates a decline in the newborn's status and requires immediate intervention to improve oxygenation.
D. Nasal flaring is a sign of respiratory distress but may not be as concerning as a low oxygen saturation level in this context. It indicates increased work of breathing but does not provide direct information about oxygenation status.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A.
Rationale:
A. Maternal cytomegalovirus can be transmitted to the newborn through contact with infected bodily fluids, including saliva and urine.
B. Airborne precautions are not necessary for cytomegalovirus, as it is primarily transmitted through contact with infected bodily fluids, not through airborne droplets.
C. There is no prophylactic treatment with acyclovir for cytomegalovirus; treatment options are limited and typically reserved for severe cases.
D. Lesions are not typically visible on the mother's genitalia with cytomegalovirus; the virus is often asymptomatic or causes mild symptoms in healthy adults.
Correct Answer is D
Explanation
Rationale:
A. Thick, white vaginal discharge is not characteristic of trichomoniasis. Trichomoniasis typically presents with a frothy, yellow-green, or grayish vaginal discharge.
B. Vulva lesions are not commonly associated with trichomoniasis. The primary symptom is vaginal discharge.
C. While urinary frequency can occur in some cases of trichomoniasis due to irritation of the urinary tract, it is not as specific a finding as the characteristic malodorous discharge.
D. Malodorous discharge is a hallmark symptom of trichomoniasis. The discharge is often described as having a foul or fishy odor and may be accompanied by itching and irritation of the genital area.
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