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 {"A":{"answers":"C"},"B":{"answers":"C"},"C":{"answers":"B"},"D":{"answers":"C"},"E":{"answers":"C"},"F":{"answers":"C"}}
Explanation
Regurgitation: Sign of Potential Worsening Condition - Regurgitation may indicate a feeding problem or gastrointestinal issue, which could worsen if not addressed.
Mottling: Sign of Potential Worsening Condition - Mottling can be a sign of poor perfusion or circulation, indicating potential worsening of the newborn's condition.
Transient strabismus: Sign of Potential Improvement - Transient strabismus, or crossed eyes, is common in newborns and often resolves on its own, indicating potential improvement.
Continuous high-pitched cry: Sign of Potential Worsening Condition - Continuous high- pitched crying may indicate discomfort or underlying pathology, suggesting potential worsening. Respiratory rate 70/min: Sign of Potential Worsening Condition - An increased respiratory rate may indicate respiratory distress or another issue, suggesting potential worsening.
Loose stools: Sign of Potential Worsening Condition - Loose stools in a newborn can be a sign of gastrointestinal upset or infection, indicating potential worsening of the newborn's condition.
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