A nurse is evaluating a newborn who was born 2 hours ago and was admitted to the neonatal intensive care unit with chest wall retractions and blue discoloration of the hands and feet.
Which finding indicates a decline in the newborn’s status?
Oxygen saturation of 89%
Nasal flaring
Fine crackles
Apneic episode less than 15 seconds
The Correct Answer is A
Choice A rationale
An oxygen saturation of 89% in a newborn who was born 2 hours ago and was admitted to the neonatal intensive care unit with chest wall retractions and blue discoloration of the hands and feet indicates a decline in the newborn’s status. This level of oxygen saturation is below the normal range for a newborn, which is typically above 95%10111213. This could indicate that the newborn is not getting enough oxygen, which could be due to a variety of conditions, including respiratory distress syndrome.
Choice B rationale
Nasal flaring is a sign of respiratory distress in a newborn. However, it is a nonspecific sign and does not necessarily indicate a decline in the newborn’s status. It could be a normal response to the newborn’s efforts to breathe more effectively.
Choice C rationale
Fine crackles can be a sign of a lung condition in a newborn. However, they are a nonspecific sign and do not necessarily indicate a decline in the newborn’s status. They could be a normal finding in a newborn who was born 2 hours ago.
Choice D rationale
An apneic episode less than 15 seconds in a newborn who was born 2 hours ago is not necessarily indicative of a decline in the newborn’s status. Brief periods of apnea (pauses in breathing) are common in newborns and are usually not a cause for concern unless they last longer than 20 seconds or are associated with other signs of distress.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
To calculate the estimated date of delivery using Nägele’s Rule, subtract three months from the first day of the last menstrual period (August 10), and then add seven days. This gives an estimated date of delivery of May 176.
Correct Answer is B
Explanation
Choice A rationale
A score of 9 on the Edinburgh Postnatal Depression Screen (EPDS) on postpartum day 2 is below the clinical cutoff score of 10, which is used to distinguish health controls versus possible depression. Therefore, this score would not indicate a high risk of developing a depressive disorder.
Choice B rationale
A score of 11 on the EPDS on postpartum day 30 is above the clinical cutoff score of 1034. This score indicates a high risk of developing a depressive disorder. Therefore, further assessment and possible intervention would be necessary.
Choice C rationale
While discharge teaching is an important aspect of postpartum care, it does not provide information about the client’s risk of developing postpartum depression. Therefore, this choice does not answer the question.
Choice D rationale
A follow-up appointment with a provider in 4 weeks is a standard part of postpartum care, but it does not provide information about the client’s risk of developing postpartum depression.
Therefore, this choice does not answer the question.
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