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 C
Explanation
Choice A rationale:
The nurse should not apply lotion to the newborn's skin during phototherapy. Phototherapy involves exposing the newborn's skin to light to treat jaundice by breaking down bilirubin. Applying lotion may interfere with the effectiveness of the therapy and may not be recommended as it can make it difficult for the skin to release heat generated during the process.
Choice B rationale:
Giving the newborn glucose water every 4 hours is not a necessary action during phototherapy. The primary concern during phototherapy is to treat jaundice, and giving glucose water may not have a direct impact on the effectiveness of the treatment. Additionally, it is important to focus on monitoring the newborn's bilirubin levels and hydration status.
Choice D rationale:
Dressing the newborn in a thin layer of clothing during phototherapy is not recommended. Phototherapy works best when the newborn's skin is exposed to a light source, and covering the skin with clothing may decrease the effectiveness of the treatment.
Correct Answer is C
Explanation
The correct answer is choice c. Heart rate 72/min.
Choice A rationale:
A blood pressure of 80/50 mm Hg is within the normal range for a full-term newborn.
Choice B rationale:
A respiratory rate of 55/min is also within the normal range for a newborn, which typically ranges from 30 to 60 breaths per minute.
Choice C rationale:
A heart rate of 72/min is significantly lower than the normal range for a newborn, which is typically between 120 to 160 beats per minute. This bradycardia should be reported to the provider as it may indicate an underlying issue.
Choice D rationale:
A temperature of 36.5°C (97.7°F) is within the normal range for a newborn, which is generally between 36.5°C to 37.5°C (97.7°F to 99.5°F).
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.