A nurse receives handoff report. Which newborn should the nurse assess first?

Glucose reading 58 mg/dL.

Pulse 144 beats/minute.

Respiratory rate 78 breaths/minute.

Temperature 97.7° F (36.5° C).

Answer and Explanation

The Correct Answer is C

Choice A reason:

While hypoglycemia (glucose <45 mg/dL) is concerning, 58 mg/dL is within acceptable ranges for many institutions, especially in asymptomatic newborns. Monitoring is required, but it is less urgent than respiratory distress.

Choice B reason:

Respiratory rate of 78 breaths per minute is also within the normal range for a newborn, which typically ranges from 30 to 60 breaths per minute. Though respiratory rate is essential to assess, it does not take priority over other critical issues.

Choice C reason:

Newborns typically have a normal respiratory rate of 30-60 breaths/minute. A rate of 78 indicates significant tachypnea, which could signal respiratory distress (e.g., transient tachypnea of the newborn, infection, or respiratory distress syndrome). Rapid breathing can lead to fatigue, hypoxia, or respiratory failure if not promptly addressed.

Choice D reason:

A glucose reading of 58 mg/dL is concerning in a newborn. Hypoglycemia (low blood glucose) can lead to serious complications if not promptly addressed. Newborns are particularly susceptible to hypoglycemia, and it requires immediate assessment and intervention.

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Correct Answer is C

Explanation

The correct answer is c. Dehydration. A significantly indented anterior fontanelle in a newborn is most commonly a sign of dehydration.

Choice A reason:

Increased intracranial pressure: This statement is incorrect because increased intracranial pressure typically causes a bulging, not indented, fontanelle. Symptoms include irritability, vomiting, and a high-pitched cry.

Choice B reason:

Vernix caseosa: This statement is incorrect because vernix caseosa is a white, cheesy substance covering the skin of newborns, unrelated to fontanelle indentation. It serves as a protective layer for the baby’s skin.

Choice C reason:

Dehydration: This statement is correct. Dehydration in newborns can cause a sunken fontanelle due to the loss of fluid. Other signs include dry mouth, sunken eyes, and fewer wet diapers.

Choice D reason:

Cyanosis: This statement is incorrect because cyanosis refers to a bluish discoloration of the skin due to lack of oxygen, not related to fontanelle shape. It indicates issues with oxygenation or circulation.

A. It produces a prolapsed cord. B. It increases maternal renal blood flow. C. It decreases maternal blood pressure. D. There is a reduction of placental blood flow.

Correct Answer is A

Explanation

Choice A reason:

One side effect of oxytocin stimulation is hypertonic contractions. This can be detrimental to the fetus because it causes a reduction of placental blood flow. Placental blood flow is essential for delivering oxygen and nutrients to the fetus and removing waste products. Hypertonic contractions are too frequent, too long, or too strong, and they can reduce the time for the placenta to refill with blood between contractions. This can lead to fetal hypoxia, acidosis, and distress.

Choice B reason:

One side effect of oxytocin stimulation is hypertonic contractions. This can be detrimental to the fetus because it produces a prolapsed cord. This is incorrect because a prolapsed cord is not caused by hypertonic contractions, but by other factors such as a low-lying placenta, a premature rupture of membranes, a small or preterm fetus, or an abnormal presentation. A prolapsed cord occurs when the umbilical cord slips through the cervix and into the vagina before or during delivery. This can compress the cord and cut off the blood supply to the fetus, resulting in fetal bradycardia and possible death.

Choice C reason:

One side effect of oxytocin stimulation is hypertonic contractions. This can be detrimental to the fetus because it increases maternal renal blood flow. This is incorrect because hypertonic contractions do not affect maternal renal blood flow directly. Maternal renal blood flow is influenced by factors such as maternal blood pressure, hydration, cardiac output, and renal function. Hypertonic contractions may cause maternal dehydration, which can reduce renal blood flow, but this is not a direct effect of oxytocin stimulation.

Choice D reason:

One side effect of oxytocin stimulation is hypertonic contractions. This can be detrimental to the fetus because it decreases maternal blood pressure. This is incorrect because hypertonic contractions do not cause maternal hypotension, but rather hypertension. Hypertension is a common side effect of oxytocin stimulation, as oxytocin causes vasoconstriction and increases the sensitivity of the vascular smooth muscle to catecholamines. Hypertension can lead to complications such as preeclampsia, eclampsia, and placental abruption.

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A nurse receives handoff report. Which newborn should the nurse assess first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse notices while holding him upright that a 1-day-old newborn has a significantly indented anterior fontanelle. She immediately brings it to the attention of the physician. What does this finding most likely indicate?

Correct Answer is C

Explanation

One side effect of oxytocin stimulation is hypertonic contractions. This can be detrimental to the fetus because

Correct Answer is A

Explanation

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