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
Choice A rationale
Transient strabismus, or temporary misalignment of the eyes, is not typically a symptom observed in newborns exposed to opioids during pregnancy.
Choice B rationale
Mottling, or patchy skin color, is a common physical characteristic in newborns and is not specifically associated with opioid exposure during pregnancy.
Choice C rationale
A respiratory rate of 70/min is significantly higher than the normal range for a newborn, which is typically between 30 and 60 breaths per minute. This could be a sign of neonatal abstinence syndrome (NAS), a group of conditions caused by withdrawal from certain drugs that the newborn was exposed to in the womb.
Choice D rationale
Loose stools are not typically associated with opioid exposure during pregnancy.
Choice E rationale
Regurgitation, or spitting up, is common in newborns and is not specifically associated with opioid exposure during pregnancy.
Correct Answer is D
Explanation
Choice A rationale
Preterm newborns do not have a thick layer of brown fat. Brown fat is a type of fat that generates heat and is typically found in full-term newborns. It helps them maintain their body temperature. Preterm newborns have less brown fat, which makes them more susceptible to hypothermia.
Choice B rationale
Shivering is a mechanism used by the body to generate heat when it’s cold. However, preterm newborns cannot shiver. Their nervous systems are not fully developed, and they lack the muscle coordination necessary to shiver.
Choice C rationale
Sweating is another mechanism the body uses to regulate temperature. When the body is too warm, it produces sweat to cool down. However, preterm newborns do not sweat to cool off when they get too warm. Their sweat glands are not fully developed, and they may not be able to sweat effectively.
Choice D rationale
Preterm newborns have less muscle tone, which exposes more body surfaces to heat loss. Muscle tone provides insulation and generates heat. Because preterm newborns have less muscle mass, they have less insulation and generate less heat, making them more susceptible to hypothermia.
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