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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. Ectopic pregnancy occurs when a fertilized egg implants outside the uterus, typically in the fallopian tube. This scenario does not match the clinical presentation described.
B. Incompetent cervix is characterized by painless cervical dilation in the second trimester and is not relevant to the clinical situation described.
C. Postpartum hemorrhage is a risk when a woman is in advanced labor with significant cervical dilation. The nurse should be vigilant for signs of hemorrhage during labor and after delivery.
D. Hyperemesis gravidarum is severe nausea and vomiting during pregnancy and is not directly related to the client's current labor status.
Correct Answer is D
Explanation
Rationale:
A. A temperature of 37.4°C (99.3°F) may be within the normal range, but it can also indicate a fever, which is common with endometritis.
B. A WBC count of 9,000/mm3 is within the normal range, but it may be elevated in response to infection such as endometritis.
C. Scant lochia is not typically associated with endometritis; instead, clients with endometritis may have increased or foul-smelling lochia.
D. Uterine tenderness is a common finding in clients with endometritis, as the infection causes inflammation and discomfort in the uterine lining.
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