A nurse is performing an initial assessment of a newborn who was delivered vaginally at term with no complications.
Which of the following findings should alert the nurse to a potential problem?
Molding of the head
Acrocyanosis of hands and feet
Nasal flaring and grunting
Vernix caseosa on skin folds
The Correct Answer is C
The correct answer is choice C. Nasal flaring and grunting are signs of respiratory distress in a newborn and should alert the nurse to a potential problem.
The nurse should monitor the newborn’s respiratory rate, oxygen saturation, and chest movements, and notify the provider if the symptoms persist or worsen.
Choice A is wrong because molding of the head is a normal finding in a newborn who was delivered vaginally.
It is caused by the pressure of the birth canal on the skull bones and usually resolves within a few days.
Choice B is wrong because acrocyanosis of hands and feet is a normal finding in a newborn during the first 24 hours of life.
It is caused by poor peripheral circulation and does not indicate hypoxia or cyanosis.
Choice D is wrong because vernix caseosa on skin folds is a normal finding in a newborn.
It is a white, cheesy substance that protects the skin from amniotic fluid and helps with thermoregulation.
It usually disappears within a few days.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is choice C. A temperature of 36°C (96.8°F) is below the normal range for a newborn, which is 36.5°C to 37.5°C (97.7°F to 99.5°F).
A low temperature can indicate hypothermia, infection, or hypoglycemia, and should be reported to the provider.
Choice A is wrong because a heart rate of 140/min is within the normal range for a newborn, which is 120 to 160/min.
Choice B is wrong because a respiratory rate of 50/min is within the normal range for a newborn, which is 30 to 60/min.
Choice D is wrong because a blood pressure of 60/40 mm Hg is within the normal range for a newborn, which is 50 to 75/30 to 45 mm Hg.
Correct Answer is A
Explanation
The correct answer is choice A. Glycogen.Preterm newborns have limited stores of glycogen, which is a substance made from glucose that is stored in the liver and muscle cells to be used later for energy.When blood glucose levels are low, the hormone glucagon signals the cells to convert glycogen back into glucose and release it into the bloodstream.However, preterm newborns have a reduced ability to produce glucagon and to use gluconeogenesis, which is the process of making new glucose from other sources.Therefore, they are at risk of hypoglycemia, which is a condition where blood glucose levels are too low to support normal brain function.
Choice B is wrong because glucose is the sugar that travels through the blood to fuel the cells, not a substance that is stored for later use.
Choice C is wrong because insulin is a hormone that helps cells absorb glucose from the blood, not a substance that is stored for later use.
Choice D is wrong because glucagon is a hormone that triggers the release of glucose from the liver and muscle cells, not a substance that is stored for later use.
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