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 A

Explanation

Choice A rationale:

The correct guidance includes giving the newborn sponge baths until the cord stump falls off, which helps to keep the area dry. It is essential to keep the umbilical cord stump clean and dry to prevent infection. Submerging the cord stump in water could increase the risk of infection.

Choice B rationale:

Covering the cord with the diaper is not advisable. The diaper could trap moisture around the cord stump, leading to a higher risk of infection. The cord stump should be exposed to air as much as possible to aid in drying and healing.

Choice C rationale:

Washing the cord with mild soap and water is not necessary and could introduce moisture, which should be avoided. Instead, the stump should be cleaned gently with a soft, dry cloth if it gets dirty.

Choice D rationale:

Wrapping the cord in petroleum jelly gauze is not a recommended practice. Applying petroleum jelly or other substances to the cord stump can interfere with the drying process and increase the risk of bacterial growth, leading to infection.

A. "I should crush cabbage leaves and place them on my breast.". B. "I will wear a snug-fitting bra.". C. "I should stimulate my nipples by squeezing softly.". D. "I will apply ice packs to my breasts.".

Correct Answer is C

Explanation

Choice A rationale:

Applying crushed cabbage leaves to the breasts can be a traditional remedy to help reduce swelling and discomfort associated with engorgement.

Choice B rationale:

Wearing a snug-fitting bra can help provide support to the breasts and reduce discomfort from breast engorgement. It can also help to avoid stimulation of the breasts, which can decrease milk production in a client who is not breastfeeding. This is an appropriate comfort measure for the client.

Choice C rationale:

Stimulating the nipples by squeezing softly can lead to increased milk production and exacerbate breast engorgement. For a client who is not breastfeeding, this action is not recommended and may worsen the engorgement.

Choice D rationale:

Applying ice packs to the breasts can help reduce inflammation and alleviate discomfort from breast engorgement. This is an appropriate comfort measure for the client who is not breastfeeding.

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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 the parents of a newborn about caring for the umbilical cord stump. Which of the following instructions should the nurse include?

Correct Answer is A

Explanation

A nurse is reinforcing teaching about comfort measures for breast engorgement with a client who is postpartum and is bottle-feeding her newborn. Which of the following statements by the client indicates a need for further teaching?

Correct Answer is C

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.).

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?

A nurse in the newborn nursery is receiving a report on four newborns. Which of the following newborns should the nurse see first?

Exhibit 1. The names of the newborn reflexes are? Select all that apply.

A nurse who is caring for a newborn observes signs of respiratory distress, jitteriness, and lethargy. Which of the following actions should the nurse take?

A nurse is caring for a client who is breastfeeding and tells the nurse that she is concerned about her newborn's hydration. Which of the following nursing observations is appropriate to use in evaluating the adequacy of the newborn's hydration?

A nurse is reviewing the laboratory results of a newborn that is 4 hr old. Which of the following findings should the nurse identify as the priority?

The medical term for the soft spot is called fontanelle.