A nurse is collecting data from a newborn 1 hr after delivery. Which of the following respiratory rates is within the expected reference range for a newborn?
22/min.
100/min.
48/min.
110/min.
The Correct Answer is C
Choice A rationale:
A respiratory rate of 22/min would be abnormally low for a newborn. The expected reference range for newborns is around 30-60 breaths per minute.
Choice B rationale:
A respiratory rate of 100/min would be abnormally high for a newborn. Such a high respiratory rate may indicate respiratory distress or other underlying issues and requires further evaluation.
Choice C rationale:
A respiratory rate of 48/min falls within the expected reference range for a newborn, which is around 30-60 breaths per minute. This rate suggests that the newborn's respiratory system is functioning within the normal range.
Choice D rationale:
A respiratory rate of 110/min would be abnormally high for a newborn. As mentioned earlier, the expected reference range for newborns is around 30-60 breaths per minute, making this rate concerning and necessitating further assessment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
The Moro reflex, also known as the startle reflex, is a normal reflex observed in newborns. To elicit this reflex, the nurse should perform a sharp hand clap or make a loud noise near the infant. This reflex is characterized by the baby's arms and legs extending outward, followed by a quick flexion, resembling a startle response. It is an important reflex to assess the newborn's neurological and motor development.
Choice B rationale:
Turning the newborn's head quickly to one side does not elicit the Moro reflex. This action may stimulate other reflexes, such as the tonic neck reflex, but it is not the appropriate method to assess the Moro reflex.
Choice C rationale:
Placing a finger at the base of the newborn's toes does not elicit the Moro reflex. This action is more related to testing the Babinski reflex, which involves the fanning and curling of the toes when the sole of the foot is stimulated.
Choice D rationale:
Holding the newborn vertically and allowing one foot to touch the crib surface does not elicit the Moro reflex. This action might elicit the stepping reflex, where the baby shows stepping movements as if walking when held in an upright position with their feet touching a surface.
Correct Answer is C
Explanation
Fetal circulation continues until after the stress of labor.
Choice A rationale:
Fetal circulation undergoes significant changes at birth. It becomes ineffective as the transition from intrauterine to extrauterine life occurs. The foramen ovale and ductus arteriosus, which allow blood to bypass certain fetal circulatory pathways, close as the baby breathes for the first time.
Choice B rationale:
Fetal circulation does not continue until red blood cells are broken down. Red blood cells in a fetus have a shorter lifespan than those in adults and are continually replaced throughout gestation. However, their breakdown is not the reason for the changes in fetal circulation.
Choice C rationale:
The correct answer. Fetal circulation continues until after the stress of labor. During labor, the baby experiences increased stress and pressure, which helps trigger various physiological changes, including the closure of specific fetal circulatory shunts.
Choice D rationale:
Fetal circulation does not continue until adulthood. As mentioned earlier, the transition from fetal to adult circulation occurs during and after birth, with the closure of specific fetal shunts and the establishment of a fully functional adult circulatory system.
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