During an observational experience in labor and delivery, the student nurse recognizes that thick meconium is present in the amniotic fluid. Upon delivery of the newborn, the student nurse understands that there are signs that indicate that the newborn will need resuscitation. These signs are:
Select one:
Central cyanosis and poor tone.
Heart rate of 160 beats per minute and spitting up mucus.
Crying with respirations of greater than 60 breaths per minute.
Blue hands and feet but lips that are slowly pinking up.
The Correct Answer is A
Choice A Reason: Central cyanosis and poor tone. These are signs of hypoxia and asphyxia in newborns, which indicate a need for resuscitation. Central cyanosis means bluish discoloration of the skin or mucous membranes around the mouth, nose, or eyes. Poor tone means limpness or lack of muscle activity.
Choice B Reason: Heart rate of 160 beats per minute and spitting up mucus. These are not signs of hypoxia or asphyxia in newborns, but rather normal findings or minor issues. A normal heart rate for a newborn ranges from 120 to 160 beats per minute. Spitting up mucus may be due to excess secretions or swallowing amniotic fluid, which can be cleared by suctioning or burping.
Choice C Reason: Crying with respirations of greater than 60 breaths per minute. These are not signs of hypoxia or asphyxia in newborns, but rather normal or expected findings. Crying indicates that the newborn has a patent airway and adequate lung expansion. Respirations of greater than 60 breaths per minute may be normal for a newborn in transition or due to transient tachypnea, which usually resolves within a few hours.
Choice D Reason: Blue hands and feet but lips that are slowly pinking up. These are not signs of hypoxia or asphyxia in newborns, but rather a common condition called acrocyanosis. Acrocyanosis means bluish discoloration of the hands and feet due to poor peripheral circulation in response to cold exposure or stress. It does not affect oxygenation or ventilation and usually disappears within 24 to 48 hours after birth.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason: "My baby will always be smaller than other babies his age." This is an incorrect answer that indicates a misconception or pessimism about SGA newborns. SGA newborns may not always be smaller than other babies their age, as they may catch up in growth and development with appropriate nutrition and care. SGA newborns may have different growth paterns depending on the cause and timing of their growth restriction.
Choice B Reason: "My baby will be okay as long as he has frequent feedings." This is an incorrect answer that indicates an oversimplification or optimism about SGA newborns. SGA newborns may not be okay with just frequent feedings, as they may have other problems or complications that require medical atention and intervention. SGA newborns may have increased nutritional needs and feeding difficulties due to low birth weight, poor suck-swallow coordination, or oral aversion.
Choice C Reason: "My baby will need to stay in the hospital until he weighs 5 pounds." This is an incorrect answer that indicates a misunderstanding or confusion about SGA newborns. SGA newborns may not need to stay in the hospital until they weigh 5 pounds, as they may be discharged earlier or later depending on their condition and readiness for home care. SGA newborns may have different criteria for discharge based on their gestational age, weight gain, feeding tolerance, temperature stability, and absence of complications.
Choice D Reason: "My baby can get cold easily, may have low blood sugar, and may have trouble breathing." This is because this statement by the parents indicates that they understand some of the common problems and complications that SGA newborns may face. SGA newborns are those who weigh less than the 10th percentile for their gestational age, which can be due to intrauterine growth restriction (IUGR) or constitutional factors. SGA newborns may have difficulties with thermoregulation, glucose metabolism, and respiratory function due to inadequate fat stores, glycogen reserves, and surfactant production.
Correct Answer is A
Explanation
Choice A Reason: Fetal movements are an indicator of fetal well-being. You should count twice a day, and you should feel ten fetal movements in 2 hours. This is because this response provides accurate and clear instructions on how to perform kick counts, which are a simple and non-invasive method of monitoring fetal activity and health. Kick counts can help detect changes in fetal movement paterns that may indicate fetal distress or hypoxia.
Choice B Reason: Here is a computer printed information packet on how to do kick counts. This is an insufficient answer that does not address the patient's question or demonstrate effective communication skills. Providing writen information alone may not ensure the patient's understanding or compliance with kick counts.
Choice C Reason: Fetal kick counts are not a reliable indicator of fetal well-being in the third trimester. This is an incorrect answer that contradicts the evidence and guidelines on kick counts. Kick counts are recommended for all pregnant women, especially in the third trimester, when fetal movements are more noticeable and consistent.
Choice D Reason: It is not important to do kick counts because you have a low-risk pregnancy. This is an incorrect answer that discourages the patient from performing kick counts and may give her a false sense of security. Kick counts are important for all pregnant women, regardless of their risk status, as they can help identify potential problems that may require further evaluation or intervention.
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