A nurse is collecting data from a term newborn who is 12 hr old. Which of the following findings should the nurse report to the provider?
Abdominal breathing
Grunting
Respiratory rate 55/min
Irregular respirations
The Correct Answer is B
A) Incorrect- Abdominal breathing is a normal pattern in newborns and does not require immediate reporting.
B) Correct - Grunting is a sign of respiratory distress in a newborn and should be reported to the provider for further evaluation.
C) Incorrect- A respiratory rate of 55/min is within the normal range for a newborn and does not require immediate reporting.
D) Incorrect- Irregular respirations are common in newborns and may not necessarily be indicative of a problem.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) Correct - An elevated respiratory rate could indicate postpartum hemorrhage as the body compensates for decreased oxygen-carrying capacity due to blood loss.
B) Incorrect- An elevated temperature might indicate infection, but it is not a specific indication of postpartum hemorrhage.
C) Incorrect- A normal apical pulse rate does not specifically indicate or rule out postpartum hemorrhage.
D) Incorrect- An elevated blood pressure might occur for various reasons postpartum, including anxiety or pain, but it is not a specific indication of postpartum hemorrhage.
Correct Answer is C
Explanation
A) Incorrect- Oxytocin is not typically administered during a nonstress test.
B) Incorrect- A nonstress test is used to assess fetal well-being and does not indicate Down syndrome.
C) Correct - A lateral tilt position (usually left lateral tilt) is recommended during a nonstress test to prevent compression of the vena cava and maintain proper blood flow to the uterus, which can optimize fetal heart rate monitoring.
D) Incorrect- NPO status is not typically required for a nonstress test. Nonstress tests are non-invasive and do not involve fasting.
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