Exhibit 1. How can the nurse assess the successful transition of the respiratory system in the newborn? (Select All that Apply.).
Dry the baby thoroughly.
Suctioning the mouth and nose with a bulb syringe to clear mucus.
Observe the chest and abdomen.
Count the number of respirations per minute.
Correct Answer : B,C,D,E
Choice A rationale:
Drying the baby thoroughly is not directly related to assessing the successful transition of the respiratory system. It is essential for warmth and comfort but does not provide specific information about the respiratory system.
Choice B rationale:
Suctioning the mouth and nose with a bulb syringe to clear mucus is important to ensure the airways are clear and the newborn can breathe effectively. This action helps assess the airway patency and successful initiation of breathing.
Choice C rationale:
Observing the chest and abdomen is crucial to assess the respiratory effort and symmetry. Normal chest movements and equal rise and fall of the abdomen indicate a successful transition of the respiratory system.
Choice D rationale:
Counting the number of respirations per minute is essential to determine if the respiratory rate falls within the expected reference range (around 30-60 breaths per minute for a newborn) and if there are any irregularities.
Choice E rationale:
Observing the color of the mucous membranes is important as cyanosis (blue discoloration) may indicate inadequate oxygenation. Pink mucous membranes are a positive sign, indicating a successful transition of the respiratory system.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Acrocyanosis, or bluish discoloration of the hands and feet, is common in the first 24 hours after birth and is typically not a cause for concern.
Choice B rationale:
A newborn not voiding within 18 hours may need evaluation, but it is not as urgent as a potential infection.
Choice C rationale:
A newborn who is 24 hours old and has not passed meconium is not the most critical concern among the options provided. While meconium (the baby's first stool) should be passed within the first 24-48 hours, a slight delay may not be an immediate cause for concern.
Choice D rationale:
The nurse should prioritize seeing the newborn with an axillary temperature of 37.8°C (100° F), as this could indicate an infection or other serious condition requiring immediate attention.
Correct Answer is C
Explanation
Choice A rationale:
(Incorrect) The newborn with significant bruising from a face presentation is at an increased risk of elevated unconjugated bilirubin levels. Bruising can lead to the breakdown of red blood cells, increasing bilirubin production.
Choice B rationale:
(Incorrect) The premature newborn is at a higher risk of elevated unconjugated bilirubin levels. Premature infants often have an underdeveloped liver, which can lead to reduced bilirubin processing and clearance.
Choice C rationale:
(Correct) The baby born at 41 weeks' gestation is at the lowest risk for elevated unconjugated bilirubin levels. By this stage, the baby's liver is more mature, allowing for efficient processing and clearance of bilirubin.
Choice D rationale:
(Incorrect) The newborn with O+ blood type, born to a mother with O- blood type, is at an increased risk of elevated unconjugated bilirubin levels if the baby's blood type is Rh-positive and the mother's is Rh-negative. This situation can lead to Rh incompatibility and hemolytic disease of the newborn, causing higher bilirubin levels.
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