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 A
Explanation
In the event of shoulder dystocia during the second stage of labor, the provider may instruct the nurse to perform the McRoberts maneuver. This involves assisting the client in pulling their knees toward their abdomen. This position effectively flattens the sacrum, changes the angle of the pelvic inlet, and allows more room for the baby to pass through the birth canal.
Correct Answer is B
Explanation
Choice A rationale
Chills are not a common side effect of clomiphene citrate.
Choice B rationale
Breast tenderness is a common side effect of clomiphene citrate. This is due to the hormonal changes induced by the medication.
Choice C rationale
Tinnitus, or ringing in the ears, is not a common side effect of clomiphene citrate.
Choice D rationale
Urinary frequency is not a common side effect of clomiphene citrate.
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