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 D
Explanation
The nurse should instruct the client to have her provider refit her for a diaphragm.
After childbirth, a woman’s body undergoes changes that may affect the fit of her diaphragm.
It is recommended that a woman be refited for a diaphragm around 6 weeks postpartum, when the uterus and cervix have returned to normal size.
Choice A is incorrect because oil-based lubricants can damage the diaphragm and reduce its effectiveness.
Water-based lubricants should be used instead.
Choice B is incorrect because storing a diaphragm in sterile water is not necessary.
The diaphragm should be washed with mild soap and water after each use and air-dried before being stored in its case.
Choice C is incorrect because the diaphragm should be kept in place for at least 6 hours after intercourse, not 4 hours.
Correct Answer is B
Explanation
When a client is receiving magnesium sulfate by continuous IV infusion for preterm labor, it is important for the nurse to review the serum medication level to ensure that the client is receiving an appropriate dose and to monitor for signs of magnesium toxicity.
Choice A is not an answer because an indirect Coombs test is used to detect antibodies against red blood cells and is not relevant to magnesium sulfate therapy.
Choice C is not an answer because liver enzymes are not directly relevant to magnesium sulfate therapy.
Choice D is not an answer because uric acid levels are not directly relevant to magnesium sulfate therapy.
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