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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A Reason: The cheek of the newborn is touched, and the newborn turns toward the side that was touched. This is an incorrect answer that describes a diﬀerent reﬂex called the rooting reﬂex. The rooting reﬂex is a feeding reﬂex that helps the newborn locate the nipple and initiate sucking. The rooting reﬂex is elicited by stroking the cheek or corner of the mouth of the newborn, which causes them to turn their head and open their mouth toward the stimulus.

Choice B Reason: The newborn is suddenly lowered or startled, and they extend their arms, legs and neck, then rapidly bring their arms together. This is because this response describes the Moro reﬂex, which is a primitive reﬂex that is present at birth and disappears by 3 to 6 months of age. The Moro reﬂex is elicited by simulating a falling sensation or a loud noise, which triggers a fear response in the newborn. The Moro reﬂex consists of four phases: extension, abduction, adduction, and crying.

Choice C Reason: The newborn is supine and their head is turned to one side, then the arm on that same side extends. This is an incorrect answer that refers to another reﬂex called the tonic neck reﬂex. The tonic neck reﬂex is a postural reﬂex that helps prepare the newborn for voluntary reaching. The tonic neck reﬂex is elicited by placing the newborn in a supine position and turning their head to one side, which causes them to assume a "fencing" posture with one arm extended and one arm ﬂexed.

Choice D Reason: The lateral aspect of the sole of the newborn's foot is stroked, and the toes extend and fan outward. This is an incorrect answer that indicates a diﬀerent reﬂex called the Babinski reﬂex. The Babinski reﬂex is a neurological reﬂex that tests for spinal cord integrity. The Babinski reﬂex is elicited by stroking the lateral aspect of the sole of the foot from heel to toe, which causes the big toe to dorsiﬂex and the other toes to fan out.

A. 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. B. Here is a computer printed information packet on how to do kick counts. C. Fetal kick counts are not a reliable indicator of fetal well-being in the third trimester. D. It is not important to do kick counts because you have a low-risk pregnancy.

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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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is performing a newborn physical assessment and is about to elicit the Moro reﬂex. Which of the following responses should the nurse expect to see? Select one:

Correct Answer is B

Explanation

The patient is 34 weeks pregnant and during a regular prenatal visit she asks how to do kick counts. The best response by the nurse would be: Select one:

Correct Answer is A

Explanation

A client who is breastfeeding her newborn tells the nurse, "I notice that when I feed him, I feel fairly strong contraction-like pain. Labor is over. Why am I having contractions now?" Which response by the nurse would be most appropriate? Select one:

At 22 weeks' gestation, a client is diagnosed with placenta previa. The doctor tells the client that the placenta may move away from the cervix as the pregnancy progresses. This is classified as what type of previa?

A couple who has had difficulty conceiving confides in the nurse at the infertility clinic that they feel overwhelmed with the decisions that face them. Which of the following nursing strategies would be most appropriate and therapeutic? Select one:

Which of the following would the nurse include in the plan of care for a newborn receiving phototherapy? Select one:

A term newborn weighs 4 pounds 5 ounces. The nurse assesses that this newborn is small for gestational age (SGA). The nurse knows that teaching has been eﬀective when the parents state: Select one:

The nurse's initial action when caring for an otherwise stable, full term infant with a slightly decreased temperature is to: Select one:

The nurse administers vitamin K intramuscularly as prophylaxis to the newborn based on which of the following rationales? Select one:

During a physical assessment of a newborn, the nurse observes bluish markings across the newborn's lower back. The nurse interprets this finding as: Select one: