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 B
Explanation
Choice A rationale:
Providing a heat source for the newborn is not the purpose of surfactant. Surfactant is a substance produced in the lungs to reduce surface tension and prevent alveolar collapse during expiration. It helps with the exchange of gases, but it does not generate heat.
Choice B rationale:
This is the correct answer. Surfactant plays a crucial role in assisting the alveoli to remain open by reducing surface tension. This, in turn, allows for proper gas exchange, especially of oxygen and carbon dioxide.
Choice C rationale:
Assisting the ductus arteriosus to remain open is not the purpose of surfactant. The ductus arteriosus is a fetal blood vessel that connects the pulmonary artery to the aorta, bypassing the lungs. After birth, it should close on its own, and surfactant does not influence this process.
Choice D rationale:
Providing energy to the newborn is not the purpose of surfactant. Energy for the newborn comes from nutrition, particularly breast milk or formula, and not from surfactant
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