The nurse assesses a 1-day-old newborn. Which finding indicates that the newborn's oxygenation needs are not being met?
Select one:
Grunting and nasal flaring.
Acrocyanosis.
Abdominal breathing.
Respiratory rate of 54 breaths/minute.
The Correct Answer is A
Choice A Reason: Grunting and nasal flaring. These are signs of respiratory distress in newborns, which indicate that their oxygenation needs are not being met. Grunting and nasal flaring. This is because grunting and nasal flaring are signs of respiratory distress in newborns, which indicate inadequate oxygenation and ventilation. Grunting is a noise made by the newborn when exhaling, which reflects an atempt to keep the alveoli open and increase lung volume.
Nasal flaring is a widening of the nostrils when inhaling, which reflects an effort to reduce airway resistance and increase airflow.
Choice B Reason: Acrocyanosis. This is not a sign of respiratory distress 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.
Choice C Reason: Abdominal breathing. This is not a sign of respiratory distress in newborns, but rather a normal patern of breathing for them. Abdominal breathing means that the newborn's abdomen rises and falls with each breath, which reflects the use of the diaphragm as the primary respiratory muscle.
Choice D Reason: Respiratory rate of 54 breaths/minute. This is not a sign of respiratory distress in newborns, but rather a normal range of respiratory rate for them. A normal respiratory rate for a newborn ranges from 40 to 60 breaths per minute.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason: Docusate sodium (Colace). This is because docusate sodium is a stool softener that can prevent constipation and straining during defecation, which can aggravate or impair the healing of a perineal laceration. A fourth-degree perineal laceration is a severe tear that extends through the skin, muscles, perineal body, and anal sphincter into the rectal mucosa. It can occur during vaginal delivery due to factors such as fetal macrosomia, forceps use, or episiotomy.
Choice B Reason: Bromocriptine (Parlodel). This is an inappropriate medication for a postpartum client with a fourth- degree perineal laceration, as it has no effect on wound healing or pain relief. Bromocriptine is a dopamine agonist that can suppress lactation by inhibiting prolactin secretion. It is used for women who do not wish to breastfeed or who have medical contraindications to breastfeeding.
Choice C Reason: Ferrous sulfate (Feosol). This is an unnecessary medication for a postpartum client with a fourth- degree perineal laceration, unless she has iron deficiency anemia. Ferrous sulfate is an iron supplement that can treat or prevent anemia by increasing hemoglobin production and oxygen-carrying capacity. Anemia can occur in the postpartum period due to blood loss during delivery or poor nutritional intake during pregnancy.
Choice D Reason: Methylergonovine (Methergine). This is an irrelevant medication for a postpartum client with a fourth-degree perineal laceration, as it does not affect wound healing or pain relief. Methylergonovine is an ergot alkaloid that can stimulate uterine contractions and reduce postpartum bleeding. It is used for women who have uterine atony or hemorrhage.
Correct Answer is C
Explanation
Choice A Reason: Obtain a bilirubin level. This is an incorrect answer that indicates an irrelevant and unnecessary nursing action for a newborn with tremors or jiteriness. Obtaining a bilirubin level is a nursing action that is indicated for a newborn with jaundice (yellowish discoloration of the skin and mucous membranes), which can occur due to increased bilirubin production or decreased bilirubin excretion. Jaundice does not cause tremors or jiteriness in newborns.
Choice B Reason: Place a pulse oximeter on the newborn. This is an incorrect answer that suggests an inappropriate and insufficient nursing action for a newborn with tremors or jiteriness. Placing a pulse oximeter on the newborn is a nursing action that measures oxygen saturation and heart rate, which can indicate hypoxia (low oxygen level) or distress in newborns. Hypoxia can cause tremors or jiteriness in newborns, but it is not the only or most likely cause. Placing a pulse oximeter on the newborn does not provide enough information to diagnose or treat hypoglycemia.
Choice C Reason: Obtain a blood glucose level. This is because tremors or jiteriness are common signs of hypoglycemia (low blood glucose) in newborns, which can occur due to various factors such as prematurity, maternal diabetes, infection, or cold stress. Hypoglycemia can cause neurological damage or death if not treated promptly and effectively. Obtaining a blood glucose level is a nursing action that has the highest priority for a newborn with tremors or jiteriness, as it can confirm the diagnosis and guide the treatment.
Choice D Reason: Take the newborn's vital signs. This is an incorrect answer that implies an inadequate and delayed nursing action for a newborn with tremors or jiteriness. Taking the newborn's vital signs is a nursing action that monitors temperature, pulse, respiration, and blood pressure, which can indicate general health status and stability in newborns. Taking the newborn's vital signs may reveal signs of hypoglycemia, such as hypothermia, tachycardia, tachypnea, or hypotension, but it is not a specific or definitive test for hypoglycemia. Taking the newborn's vital signs may also waste valuable time that could be used to obtain a blood glucose level and initiate treatment.
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