A nurse is assessing the breath sounds of a newborn. Which sound is an expected finding for this developmental level?
Bruits
Crackles
Wheezing
Stridor
The Correct Answer is D
Stridor is a high-pitched, inspiratory sound that indicates partial obstruction of the upper airway. It is a common finding in newborns and can occur due to the presence of mucus, fluid, or a small airway that has not yet fully developed. It is important to note that while stridor is an expected finding in newborns, it should still be assessed and monitored closely by healthcare professionals.
Bruits are abnormal sounds heard over blood vessels and are not related to breath sounds. Crackles are a series of brief, discontinuous, nonmusical sounds heard during inspiration or expiration, indicating fluid in the lungs. Wheezing is a high-pitched, musical sound heard during expiration and can indicate the narrowing of the airways. These sounds are not typically expected in the breath sounds of a newborn.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
When someone has asthma, their lungs may produce a wheezing sound when they breathe in and out. Narrowed airways and restricted air movement through the lungs may be responsible for the wheezing sound.
Correct Answer is A
Explanation
Pulse oximetry is a non-invasive method of monitoring the oxygen saturation level in the blood. A normal range for oxygen saturation is between 95% and 100%. An oxygen saturation level of 89% indicates hypoxemia, which is a serious condition that can lead to tissue damage, organ failure, and even death if left untreated.
Therefore, the priority nursing action is to perform a respiratory assessment to determine the cause of the hypoxemia. This should include assessing the client's airway patency, breathing patern, lung sounds, and oxygen therapy if the client is already receiving it. The nurse should also observe for any signs of respiratory distress such as cyanosis, accessory muscle use, or difficulty breathing.
While it is important to document hypoxemia and report it to the healthcare provider, the priority at this time is to assess and intervene promptly to prevent further deterioration of the client's condition. Checking the placement of the pulse oximeter may be necessary if the reading is unreliable, but it is not the priority in this scenario.
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