Following a vaginal delivery, the nurse places the neonate under the radiant warmer to elicit spontaneous respirations.

The newborn has a heart rate of 100 beats per minute and remains apneic when the nurse flicks the soles of the feet.

Which action should the nurse implement next?

Give blow-by oxygen via cannula.

Start IV infusion in a scalp vein.

Assist neonatologist with intubation.

Provide positive pressure ventilation.

Answer and Explanation

The Correct Answer is D

Choice A rationale

Blow-by oxygen delivery can provide some additional oxygen to the apneic newborn, but it may not be effective in stimulating breathing or providing adequate ventilation. It is a less direct method of addressing apnea compared to positive pressure ventilation.

Choice B rationale

Starting an IV infusion in a scalp vein is important for medication administration or fluid resuscitation but is not the immediate priority for a newborn who is apneic and has a heart rate of 100 beats per minute. Establishing adequate ventilation takes precedence to ensure oxygenation and stabilize the newborn.

Choice C rationale

Assisting the neonatologist with intubation may be necessary if positive pressure ventilation is unsuccessful or if there are signs of severe respiratory distress. However, the immediate next step for an apneic newborn with a heart rate of 100 beats per minute should be to provide positive pressure ventilation to stimulate breathing.

Choice D rationale

Providing positive pressure ventilation is the recommended immediate action for a newborn who remains apneic and has a heart rate of less than 100 beats per minute. This intervention helps to inflate the lungs, establish effective breathing, and improve oxygenation, which is critical for the newborn's survival.

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Correct Answer is C

Explanation

Choice A rationale

Diaphragmatic respirations are a normal breathing pattern and do not indicate respiratory distress. In fact, diaphragmatic breathing can be beneficial for patients with respiratory conditions as it helps to maximize lung expansion and improve oxygenation. Therefore, this finding is not indicative of acute respiratory distress in a child with asthma.

Choice B rationale

Bilateral bronchial breath sounds are usually heard over the large airways, such as the trachea and the main bronchi, and are not typically associated with acute respiratory distress. Wheezing or diminished breath sounds would be more indicative of airway obstruction and respiratory distress in a child with asthma.

Choice C rationale

Flaring of the nares is a sign of increased respiratory effort and is commonly seen in children with acute respiratory distress. This indicates that the child is struggling to breathe and is using additional muscles to help with respiration, which is a concerning sign that requires immediate attention.

Choice D rationale

A resting respiratory rate of 35 breaths per minute is elevated for a 3-year-old child but is not the most specific sign of acute respiratory distress. While tachypnea can indicate respiratory distress, other signs, such as nasal flaring, retractions, and cyanosis, are more specific indicators of the severity of the child's condition. .

A. Have the antibiotic trough level drawn within 3 days. B. Continue strict monitoring of daily wet diapers for 1 week. C. Administer antipyretic medication on a continuous basis. D. Monitor the infant for response to auditory stimuli.

Correct Answer is D

Explanation

Choice A rationale

In bacterial meningitis, monitoring antibiotic levels is critical during treatment to ensure therapeutic effectiveness and avoid toxicity. However, it is not necessary to check antibiotic levels after completing the course. The body clears the antibiotics within a few days, and monitoring is more relevant during therapy.

Choice B rationale

While monitoring wet diapers is important during illness, it's not necessary to continue strict monitoring post-treatment. Wet diapers track hydration and renal function, which should normalize after successful treatment.

Choice C rationale

Continuous use of antipyretics is unnecessary post-treatment. Fever management is more critical during active infection. Post-treatment, fevers should subside, making continuous medication redundant and possibly harmful.

Choice D rationale

Auditory monitoring is crucial after meningitis due to the risk of hearing loss, a common complication. Early detection of auditory issues allows for timely intervention and support for the child’s development.

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Following a vaginal delivery, the nurse places the neonate under the radiant warmer to elicit spontaneous respirations. The newborn has a heart rate of 100 beats per minute and remains apneic when the nurse flicks the soles of the feet. Which action should the nurse implement next?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A parent rushes their 3-year-old child to the emergency department with an asthma exacerbation. Which additional finding should alert the nurse that the child is in acute respiratory distress?

Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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Following a vaginal delivery, the nurse places the neonate under the radiant warmer to elicit spontaneous respirations.

The newborn has a heart rate of 100 beats per minute and remains apneic when the nurse flicks the soles of the feet.

Which action should the nurse implement next?