A nurse is caring for four newborns.
Which of the following newborns should the nurse assess first?
A newborn who has subconjunctival hemorrhage of the left eye.
A newborn who has rust-stained urine.
A newborn who has nasal flaring.
A newborn who has overlapping suture lines.
The Correct Answer is C
Choice A rationale
Subconjunctival hemorrhage is a common, generally benign finding in newborns, often resulting from increased intraocular pressure during the birthing process, causing rupture of superficial capillaries in the sclera. It presents as a bright red patch under the conjunctiva and usually resolves spontaneously within a few weeks without intervention, thus it does not warrant immediate, priority assessment.
Choice B rationale
Rust-stained urine, or pink-tinged urine, in a newborn is typically due to the presence of uric acid crystals (urates) in the urine, a normal finding related to concentrated urine and the immaturity of the newborn kidney's ability to concentrate urine fully. This is a common, non-pathological observation in the first few days of life, indicating mild dehydration, but it is not an acute, high-priority concern.
Choice C rationale
Nasal flaring is a significant sign of respiratory distress in a newborn, indicating the infant is attempting to increase the diameter of the nasal passages to decrease airway resistance and enhance the intake of oxygen. This compensatory mechanism suggests compromised gas exchange and potential hypoxemia, requiring immediate assessment and intervention to prevent further respiratory compromise.
Choice D rationale
Overlapping suture lines, also known as molding, occurs when the cranial bones shift and overlap during passage through the narrow birth canal. This is a normal, expected finding, especially after a vaginal delivery, and the shape of the head typically returns to normal within a few days to a week, posing no immediate threat to the newborn.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
A fetal heart rate (FHR) of 150/min with moderate variability is within the normal range (110-160/min) and suggests adequate fetal oxygenation, which is less indicative of a significant Grade 2 abruption. A Grade 2 (moderate) abruption typically involves 20%-50% placental separation, often resulting in fetal distress like persistent late decelerations or tachycardia as a compensatory response to hypoxemia.
Choice B rationale
Placenta previa, not abruption, classically presents with painless, bright red vaginal bleeding due to the placenta covering the cervical os. Placental abruption, caused by premature separation of the placenta from the uterine wall, typically causes bleeding accompanied by significant, severe, and unrelenting abdominal pain due to concealed hemorrhage and uterine irritability.
Choice C rationale
A soft abdomen suggests a relaxed uterus, which is normal. In Grade 2 placental abruption, blood often becomes trapped between the placenta and uterine wall, causing uterine tetany or hypertonicity (increased muscle tone) and rigidity, which presents as a firm or board-like abdomen that is tender to palpation.
Choice D rationale
A heart rate of 120/min (tachycardia) in the client is an expected finding in a moderate (Grade 2) placental abruption. The client is experiencing hypovolemia due to hemorrhage (internal and/or external bleeding), which triggers a compensatory sympathetic nervous system response, increasing the heart rate to maintain cardiac output and tissue perfusion.
Correct Answer is B
Explanation
Choice A rationale
Asking about the fluid's color (clear, meconium-stained, bloody) provides information about fetal well-being and potential complications (like meconium aspiration), but it is a secondary assessment. While important, it does not supersede the need to immediately assess the most urgent physiological parameter of fetal status, which is the heart rate.
Choice B rationale
The rupture of membranes (water breaking) carries a risk of prolapsed umbilical cord, which can severely compromise fetal oxygenation by compressing the umbilical vessels. Determining the fetal heart rate (FHR) immediately is the priority action to identify signs of fetal distress, such as bradycardia (FHR <110 beats/min), indicating cord compression. The normal FHR range is 110-160 beats/min.
Choice C rationale
Monitoring cervical dilation is necessary to determine the stage and progress of labor. However, in the setting of ruptured membranes, assessing the immediate safety and stability of the fetus takes precedence over checking labor progress. A vaginal exam to check dilation is done after assessing FHR and ruling out immediate emergencies like cord prolapse.
Choice D rationale
Determining the vaginal pH with Nitrazine paper can confirm if the fluid is amniotic fluid (alkaline, pH 7.0-7.5) or urine/vaginal secretions (acidic). While this confirms the rupture of membranes, establishing the status of the fetus by assessing the FHR is the most critical and life-saving priority action to take first to prevent or quickly address fetal hypoxia.
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