A nurse is caring for a newborn in the neonatal unit following delivery.
Complete the following sentence by using the list of options.
The nurse should further evaluate
The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C"}
The nurse should further evaluate respiratory characteristics and muscle tone to determine if the newborn is experiencing a complication.
Rationale for correct answers
Respiratory characteristics are critical to assess because irregular and shallow breathing in a newborn can indicate neurological or respiratory dysfunction. Normal neonatal respiratory rate ranges from 30 to 60 breaths per minute with regular pattern; deviations may signal distress or central nervous system issues. Muscle tone evaluation is essential since increased tone with tremors suggests possible neurologic irritability or withdrawal. Normal newborn muscle tone should be moderate, neither hypotonic nor hypertonic, with symmetrical movement. These signs correlate with the high-pitched cry, tremors, and exaggerated reflexes noted, which may indicate neurological complications such as withdrawal syndrome or hypoxic-ischemic encephalopathy.
Rationale for incorrect answers
Heart rate (A) is important but was not reported abnormal; normal neonatal heart rate ranges from 120 to 160 beats per minute and the absence of murmurs suggests no cardiac compromise. Temperature (C) is less urgent as mucous membranes are moist and skin warm and dry, indicating stable thermoregulation; normal newborn temperature is 36.5–37.5°C. Feeding patterns (D) appear adequate with no difficulty reported, making this less immediately concerning.
Rationale for incorrect answers
Moro reflex (A) and Babinski reflex (B) are both present and exaggerated, which may be reactive but less specific for immediate concern than muscle tone abnormalities. Skin color (D) is normal without cyanosis or jaundice, reducing the likelihood of hypoxia or hemolytic issues.
Take home points
- Respiratory pattern irregularities in newborns may indicate neurological or respiratory dysfunction.
- Abnormal muscle tone and tremors are key signs of potential neurological complications.
- Normal heart rate, temperature, feeding, and skin color reduce likelihood of cardiac or systemic illness.
- Reflex exaggeration alone is less specific than muscle tone and respiratory changes for early complication detection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Herpes simplex virus 2 (HSV-2) can be harmful to a developing fetus and newborn. While primary infection during the first trimester can rarely lead to congenital anomalies, the most significant risk is neonatal herpes, which occurs when the newborn is exposed to the virus during passage through the birth canal if active lesions are present. Neonatal herpes can cause severe, life-threatening complications.
Choice B rationale
Transmission of HSV-2 to the newborn is significantly higher if active genital lesions are present at the time of vaginal birth. The virus can be shed from these lesions and infect the infant as they pass through the birth canal. Therefore, a Cesarean section is typically recommended if active lesions are present at the onset of labor.
Choice C rationale
Wearing tight-fitting undergarments can increase moisture and friction, potentially irritating existing lesions and hindering healing. Loose-fitting cotton undergarments are generally recommended to allow air circulation and reduce irritation, promoting a more favorable environment for lesion resolution and comfort.
Choice D rationale
Antiviral medications, such as acyclovir, valacyclovir, or famciclovir, can help manage genital herpes by reducing the frequency, duration, and severity of outbreaks. They work by inhibiting viral replication. However, these medications do not cure the condition; HSV-2 remains a lifelong viral infection.
Correct Answer is D
Explanation
Choice A rationale
A client at 12 weeks of gestation not feeling fetal movement is expected. Fetal movement, or quickening, typically begins between 16 and 20 weeks of gestation for primigravidas and earlier for multigravidas. At 12 weeks, the fetus is still small and movements are not usually strong enough to be consistently perceived by the mother, thus this finding is not immediately concerning.
Choice B rationale
A fetal heart rate (FHR) of 160/min at 28 weeks of gestation is within the normal range, which is typically 110-160 beats/min. A normal FHR indicates adequate fetal oxygenation and well-being. Therefore, this finding does not suggest an emergent situation requiring immediate provider assessment.
Choice C rationale
Deep tendon reflexes (DTRs) graded as 2+ are considered normal. This grading indicates an average, brisk reflex response. Abnormal DTRs, such as hyperreflexia (3+ or 4+), can be indicative of preeclampsia, but a 2+ finding is physiological and does not warrant immediate concern.
Choice D rationale
Blurred vision in a client at 36 weeks of gestation can be a symptom of preeclampsia, a serious hypertensive disorder of pregnancy. This condition can lead to severe complications such as eclampsia, placental abruption, or HELLP syndrome, requiring immediate medical evaluation and intervention to prevent adverse maternal and fetal outcomes.
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