A nurse is completing a full assessment of a newborn at 4 hours of life.
For each of the assessment findings below, click to specify if this is an expected (normal) newborn finding or an abnormal finding.
Note: each column must have at least one response option selected.
Milia
Barrel-shaped chest
Respiratory rate 66/min
Acrocyanosis present
Polydactyly
The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"B"}}
A. Milia: Expected (normal) finding.
B. Barrel-shaped chest: Expected (normal) finding.
C. Respiratory rate 66/min: Abnormal finding.
D. Acrocyanosis present: Expected (normal) finding.
E. Polydactyly: Abnormal finding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Erythema toxicum is a common, benign rash in newborns but does not cause swelling that crosses suture lines.
Choice B rationale
A caput succedaneum is swelling of the scalp that crosses suture lines and is caused by prolonged pressure on the head during delivery.
Choice C rationale
Mongolian spots are benign, flat, congenital birthmarks with wavy borders and irregular shapes, typically found on the lower back and buttocks, not the head.
Choice D rationale
A cephalhematoma is a collection of blood between the skull bone and its periosteum that does not cross suture lines. .
Correct Answer is D
Explanation
Choice D rationale
The normal respiratory rate for a newborn is between 30 to 60 breaths per minute. A rate of 60/min is within this range.
Choice A rationale
A respiratory rate of 110/min is too high for a newborn and may indicate respiratory distress.
Choice B rationale
A respiratory rate of 100/min is also too high for a newborn and may indicate respiratory distress.
Choice C rationale
A respiratory rate of 24/min is too low for a newborn and may indicate respiratory depression.
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