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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

"Baby powder will help prevent a diaper rash.”.

Choice A rationale:

"I will use mild soap”. indicates an appropriate understanding of newborn bathing. Mild soap is suitable for newborn skin to avoid irritation.

Choice B rationale:

This is the correct answer. Baby powder is not recommended for newborns as it can cause respiratory issues when inhaled and may lead to skin irritation. Therefore, the client needs further teaching about the use of baby powder.

Choice C rationale:

"I will test the water on my wrist for temperature before bathing”. demonstrates proper safety measures, ensuring the water is not too hot for the baby.

Choice D rationale:

"I will use a basin during bathing”. is a reasonable approach to bathing the newborn and does not indicate a need for further teaching.

A. Respiratory distress. B. Hyperglycemia. C. Metabolic alkalosis. D. Hypoglycemia.

Correct Answer is ["A","D"]

Explanation

Choice A rationale:

Respiratory distress is a priority assessment finding that indicates a newborn may be experiencing cold stress. Cold stress can cause the baby's body to burn brown fat to generate heat, leading to increased oxygen demand and respiratory distress as a compensatory mechanism.

Choice B rationale:

Hyperglycemia is not associated with cold stress. Instead, hypoglycemia (low blood sugar) is a concern in newborns experiencing cold stress as they deplete their glucose stores to maintain body temperature.

Choice C rationale:

Metabolic alkalosis is not a priority assessment finding for cold stress. Metabolic acidosis (not listed in the options) can be associated with cold stress due to increased anaerobic metabolism, but it is not one of the provided choices.

Choice D rationale:

Hypoglycemia is a priority assessment finding associated with cold stress. As the baby's body uses glucose to produce heat from burning brown fat, it can lead to a drop in blood sugar levels, which is a significant concern in newborns.

Choice E rationale:

Metabolic acidosis is not listed among the provided choices, but it can be associated with cold stress due to the increased production of lactic acid from anaerobic metabolism when trying to generate heat.

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Exhibit 1. How can the nurse assess the successful transition of the respiratory system in the newborn? (Select All that Apply.).

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a client who is postpartum about bathing her newborn. Which of the following statements by the client indicates a need for further teaching?

Correct Answer is B

Explanation

Exhibit 1. A nurse understands which of the following assessment findings as a priority to indicate that a newborn may be experiencing cold stress and burning brown fat to produce heat? (Select all that apply.).

Correct Answer is ["A","D"]

Explanation

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