A nurse is collecting data from a newborn. Which of the following anatomical landmarks should the nurse use to measure chest circumference?
Sternal notch.
Nipple line.
Lower ribcage border.
Axillae.
The Correct Answer is B
The nurse should use the lower ribcage border to measure chest circumference.
Choice A rationale:
The sternal notch is not an appropriate landmark for measuring chest circumference. It is a notch at the top of the sternum and not indicative of chest circumference.
Choice B rationale:
When measuring the chest circumference of a newborn, the correct anatomical landmark to use is the nipple line. This method ensures that the measurement is taken at a consistent and reproducible location across different individuals, providing an accurate assessment of the chest size relative to growth and development standards. It's important to position the measuring tape at the level of the nipples, encircling the chest at its largest point, which typically aligns with the nipple line.
Choice C rationale:
The lower ribcage border is also not suitable as it may vary significantly with respiratory movements and is not a stable landmark for consistent measurements.
Choice D rationale:
The axillae (armpits) are not used as a landmark for measuring chest circumference. It is not a standardized anatomical point for this purpose.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
The correct guidance includes giving the newborn sponge baths until the cord stump falls off, which helps to keep the area dry. It is essential to keep the umbilical cord stump clean and dry to prevent infection. Submerging the cord stump in water could increase the risk of infection.
Choice B rationale:
Covering the cord with the diaper is not advisable. The diaper could trap moisture around the cord stump, leading to a higher risk of infection. The cord stump should be exposed to air as much as possible to aid in drying and healing.
Choice C rationale:
Washing the cord with mild soap and water is not necessary and could introduce moisture, which should be avoided. Instead, the stump should be cleaned gently with a soft, dry cloth if it gets dirty.
Choice D rationale:
Wrapping the cord in petroleum jelly gauze is not a recommended practice. Applying petroleum jelly or other substances to the cord stump can interfere with the drying process and increase the risk of bacterial growth, leading to infection.
Correct Answer is D
Explanation
A. Back to sleep: While placing babies on their backs to sleep is essential for reducing the risk of sudden infant death syndrome (SIDS), it does not prevent flat spots. Instead, tummy time while the baby is awake helps balance the time spent on their back.
B. Take the baby for walks: Taking a baby for walks is beneficial for overall development and stimulation but does not directly prevent flat spots on the head.
C. Keep them awake most of the day: This is not a safe or recommended practice. Babies need sufficient sleep for proper growth and development.
D. Tummy time helps prevent flat spots by reducing the amount of time the baby spends lying on their back. It also strengthens neck, shoulder, and arm muscles, encouraging the baby to move their head more freely and develop motor skills.
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