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.

Answer and Explanation

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.

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Correct Answer is B

No explanation

A. The mother and the father are both Rh positive. B. The mother is Rh positive and the father is Rh negative. C. The mother is Rh negative and the father is Rh positive. D. The mother and the father are both Rh negative.

Correct Answer is C

Explanation

Choice A rationale:

If both the mother and the father are Rh positive, there is no risk of hemolytic disease in the newborn due to Rh incompatibility. Hemolytic disease of the newborn occurs when the mother is Rh negative and the father is Rh positive.

Choice B rationale:

When the mother is Rh positive and the father is Rh negative, there is no risk of hemolytic disease in the newborn. Hemolytic disease results from Rh incompatibility, which occurs when the mother is Rh negative, and the father is Rh positive.

Choice C rationale:

This is the correct answer. Hemolytic disease of the newborn occurs when the mother is Rh negative, and the father is Rh positive. In such cases, the baby may inherit the Rh factor from the father, leading to Rh incompatibility between the mother and the baby's blood, potentially causing hemolytic disease.

Choice D rationale:

If both the mother and the father are Rh negative, there is no risk of hemolytic disease in the newborn due to Rh incompatibility. Hemolytic disease of the newborn occurs when the mother is Rh negative and the father is Rh positive.

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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?

Nursing Test Bank

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