During a newborn assessment, which symptom, if present, would indicate respiratory distress?

Shallow and irregular respirations.

Respiratory rate of 50 breaths per minute.

Flaring of the nares.

Abdominal breathing with synchronous chest movement.

Answer and Explanation

The Correct Answer is C

Choice A rationale

While shallow and irregular respirations can be a sign of respiratory distress in newborns, it is not the most indicative symptom. Newborns naturally have irregular breathing patterns, which can include periods of rapid breathing followed by periods of no breathing for up to 10 seconds.

Choice B rationale

A respiratory rate of 50 breaths per minute is within the normal range for a newborn. Newborns typically breathe at a rate of 40 to 60 breaths per minute.

Choice C rationale

Flaring of the nares, or nostrils, is a common sign of respiratory distress in newborns. It indicates that the baby is working hard to breathe.

Choice D rationale

Abdominal breathing with synchronous chest movement is normal in newborns. It is not a sign of respiratory distress.

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Correct Answer is B

Explanation

Choice A rationale

Covering the lesion with a dressing is not the standard care for a pregnant client with active herpes lesions. Herpes can be transmitted to the baby during a vaginal birth, even if lesions are covered.

Choice B rationale

Preparing for a cesarean section is the correct action. A cesarean section is often recommended for women with active genital herpes lesions to prevent transmission of the virus to the baby during delivery.

Choice C rationale

Obtaining blood cultures is not typically necessary for a client with active herpes lesions. Herpes is a viral infection, and its presence is usually determined through a visual examination of lesions and sometimes a swab of the lesion, not through blood cultures.

Choice D rationale

Administering penicillin is not the correct action. Penicillin is an antibiotic, which is used to treat bacterial infections, not viral infections like herpes.

A. Clean up the spit-up and assist the mother with the diaper change. B. Position the newborn on the side and suction the mouth and nares with a bulb syringe. C. Position the newborn with the head lower than the feet. D. Sit the newborn upright and burp by gently rubbing or patting the upper back.

Correct Answer is D

Explanation

Answer: D. Sit the newborn upright and burp by gently rubbing or patting the upper back.

Rationale:

Choice A: Clean up the spit-up and assist the mother with the diaper change is not the first priority. While cleaning is important, ensuring the baby's airway is clear and preventing aspiration (inhaling vomit into the lungs) is more critical.
Choice B: Position the newborn on the side and suction the mouth and nares with a bulb syringe is only necessary if the baby shows signs of respiratory distress, such as coughing, wheezing, or difficulty breathing. Unless aspiration is suspected, suctioning can irritate the nasal passages and worsen the situation.
Choice C: Position the newborn with the head lower than the feet can actually increase the risk of aspiration. Fluids can pool in the back of the throat and be more easily inhaled.
Choice D: Sit the newborn upright and burp by gently rubbing or patting the upper back is the most appropriate first action. This position helps bring up any air swallowed during feeding, reducing the likelihood of spitting up. Gently rubbing or patting the back encourages the burp reflex.

Additional Notes:

After burping the baby, the nurse can assess the amount of spit-up and clean the baby and surrounding area as needed.
If the baby shows signs of respiratory distress after burping, suctioning may be necessary. However, this should only be done by a healthcare professional.
If the spitting up is frequent or forceful, the nurse should consult with a doctor to rule out any underlying medical conditions.

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During a newborn assessment, which symptom, if present, would indicate respiratory distress?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A multiparous client with active herpes lesions has been admitted to the unit due to spontaneous rupture of membranes.What action should the nurse take?

Correct Answer is B

Explanation

After breastfeeding for 10 minutes on each breast, a new mother calls the nurse to the postpartum room to assist with changing the newborn’s diaper. As the mother begins the diaper change, the newborn regurgitates the breast milk. What should be the nurse’s first action?

Correct Answer is D

Explanation

Answer: D. Sit the newborn upright and burp by gently rubbing or patting the upper back.

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