A nurse is caring for a newborn.
Which of the following assessment findings should indicate to the nurse that suctioning of the nasopharynx is needed?
The newborn's respiratory rate is 32/min.
The newborn's respiratory rate is irregular.
The newborn is beginning to cough.
The newborn's pulse oximetry is 91.
None of the above
The Correct Answer is E
None of the choices provided indicate that suctioning of the nasopharynx is needed for a newborn.
Nasopharyngeal suctioning is performed to remove mucus or saliva from the back of the throat when a newborn is unable to cough or swallow. It is commonly used in infants with bronchiolitis.
Choice A, “The newborn’s respiratory rate is 32/min,” is not an answer because a respiratory rate of 32/min is within the normal range for a newborn.
Choice B, “The newborn’s respiratory rate is irregular,” is not an answer because irregular breathing paterns are common in newborns.
Choice C, “The newborn is beginning to cough,” is not an answer because coughing is a normal reflex that helps clear the airway.
Choice D, “The newborn’s pulse oximetry is 91,” is not an answer because pulse oximetry measures oxygen saturation and does not indicate the need for nasopharyngeal suctioning.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A nurse should report absent deep-tendon reflexes to the provider when a client is receiving magnesium sulfate via continuous IV infusion.
This is because reduced tendon reflexes can be a side effect of magnesium sulfate use during pregnancy.
Choice A is not correct because a decrease in the frequency of contractions is an expected outcome of magnesium sulfate use as a tocolytic to stop preterm labor.
Choice B is not correct because a urinary output of 35 mL/hr is within the normal range.
Choice D is not correct because an elevated blood pressure is not a known side effect of magnesium sulfate use during pregnancy.
Correct Answer is A
Explanation
“I should increase my calcium intake while taking this medication.” A client who is receiving medroxyprogesterone IM for contraception should increase their calcium intake while taking this medication .
Medroxyprogesterone can cause loss of bone mineral density which can increase the risk of osteoporosis. Increasing calcium intake can help maintain bone health.
Choice B, “I should discontinue this medication if I experience spotting,” is not an answer because spotting is a common side effect of medroxyprogesterone and does not require discontinuation of the medication.
Choice C, “I will need to return to the clinic in 8 weeks for my next injection,” is not an answer because medroxyprogesterone IM is given every 3 months, not every 8 weeks.
Choice D, “I will get two shots each time I receive this medication,” is not an answer because only one injection is given at a time.
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