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 irregular.
The newborn's respiratory rate is 32/min.
The newborn's pulse oximetry is 91%.
The newborn is beginning to cough.
The Correct Answer is D
The correct answer is **d. The newborn is beginning to cough**.
Choice A rationale:
An irregular respiratory rate in a newborn is not necessarily an indication for nasopharyngeal suctioning. Irregular respirations can have various causes, and suctioning may not be the appropriate intervention.
Choice B rationale:
A respiratory rate of 32 breaths per minute is within the normal range for a newborn and does not indicate the need for nasopharyngeal suctioning.
Choice C rationale:
A pulse oximetry reading of 91% is low and may indicate the need for intervention, but it does not specifically indicate the need for nasopharyngeal suctioning. Other interventions, such as supplemental oxygen, may be more appropriate.
Choice D rationale:
The newborn beginning to cough is a clear indication that there may be secretions or obstruction in the nasopharynx, and suctioning may be necessary to clear the airway and improve respiratory function.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Swaddling the newborn with his legs extended is not the appropriate action for a newborn with neonatal abstinence syndrome (NAS). NAS occurs when a baby is born dependent on drugs, usually because the mother used opioids during pregnancy. Swaddling may provide some comfort, but extending the legs could increase discomfort and agitation.
Choice B rationale:
Scheduling larger volume feedings at less frequent intervals is not the correct approach for a newborn with NAS. These infants often have feeding difficulties and may require smaller, more frequent feedings to reduce the risk of aspiration.
Choice C rationale:
Maintaining eye contact with the newborn during feedings may not be well-tolerated by a baby with NAS. They can be irritable and easily overstimulated, and eye contact during feeding may exacerbate their agitation.
Choice D rationale:
Planning care to minimize handling of the newborn is the most appropriate action for a baby with NAS. These infants are sensitive to stimuli and can become agitated easily, so minimizing unnecessary handling helps reduce their distress.
The correct answer is D. Plan care to minimize handling of the newborn.
Here's why:
- Swaddling with legs extended: This is not recommended as it can be uncomfortable for the newborn and may exacerbate withdrawal symptoms.
- Larger volume feedings at less frequent intervals: This can be difficult for newborns with NAS due to their increased metabolic rate and may lead to overfeeding.
- Maintaining eye contact during feedings: While this is important for bonding, it can be overwhelming for newborns with NAS, who often prefer a calm environment.
Minimizing handling is a key intervention in caring for newborns with NAS. Excessive handling can trigger withdrawal symptoms and make the newborn more irritable. Instead, focus on gentle, soothing techniques like swaddling with arms tucked in, rocking, and providing a quiet, dimly lit environment.
Correct Answer is C
Explanation
Choice A rationale:
Oatmeal is a good source of fibre, but its fibre content per cup is not as high as some other options.
Choice B rationale:
Cabbage is a healthy choice with some fibre content, but it does not have as much fibre per cup as lentils.
Choice C rationale:
Lentils have the highest fibre content per cup compared to the other options listed. They are rich in both soluble and insoluble fibre, which helps promote bowel regularity and alleviate constipation.
Choice D rationale:
Asparagus is a nutritious vegetable but does not have as much fibre per cup as lentils.
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