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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A Reason: Frequent voiding encourages sphincter control. This is an incorrect statement that has no relevance to labor and delivery. Sphincter control refers to the ability to contract and relax the muscles that control urination and defecation. It is not aﬀected by frequent voiding.

Choice B Reason: A full bladder impedes oxygen ﬂow to the fetus. This is an incorrect statement that confuses a full bladder with a prolapsed cord. A prolapsed cord is a condition where the umbilical cord slips through the cervix before the baby and becomes compressed by the fetal head, which can reduce oxygen ﬂow to the fetus. A full bladder does not aﬀect oxygen ﬂow to the fetus.

Choice C Reason: Frequent voiding prevents bruising of the bladder. This is an incorrect statement that exaggerates the eﬀect of a full bladder on the bladder wall. A full bladder may cause some pressure or discomfort on the bladder, but it does not cause bruising or damage.

Choice D Reason: A full bladder can impede fetal descent. This is a correct statement that explains why it is important for the nurse to assess the bladder regularly and encourage the laboring client to void every 2 hours.

A. Vitamin K will increase erythropoiesis. B. Vitamin K will enhance bilirubin breakdown. C. Vitamin K will stop Rh sensitization. D. Vitamin K will promote blood clotting ability. Vitamin K will promote blood clotting ability.

Correct Answer is D

Explanation

Choice A Reason: Vitamin K will increase erythropoiesis. This is an incorrect statement that confuses vitamin K with erythropoietin. Erythropoietin is a hormone that stimulates red blood cell production in the bone marrow. Vitamin K does not aﬀect erythropoiesis.

Choice B Reason: Vitamin K will enhance bilirubin breakdown. This is an incorrect statement that confuses vitamin K with phototherapy. Phototherapy is a treatment that exposes the newborn's skin to light, which converts bilirubin into water-soluble forms that can be excreted by the liver and kidneys. Bilirubin is a yellow pigment that results from the breakdown of red blood cells. High levels of bilirubin can cause jaundice and brain damage in newborns. Vitamin K does not aﬀect bilirubin metabolism.

Choice C Reason: Vitamin K will stop Rh sensitization. This is an incorrect statement that confuses vitamin K with Rh immune globulin. Rh immune globulin is an injection given to Rh-negative mothers who deliver Rh-positive babies, to prevent them from developing antibodies against Rh-positive blood cells in future pregnancies. Rh sensitization is a condition where the mother's immune system atacks the baby's blood cells, causing hemolytic disease of the newborn. Vitamin K does not aﬀect Rh sensitization.

Choice D Reason: Vitamin K will promote blood clotting ability. This is a correct statement that explains the rationale for administering vitamin K as prophylaxis to newborns. Vitamin K is essential for the synthesis of clotting factors in the liver. Newborns have low levels of vitamin K at birth due to poor placental transfer and lack of intestinal bacteria that produce vitamin K. Therefore, they are at risk of bleeding disorders such as hemorrhagic disease of the newborn.

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The nurse assesses a 1-day-old newborn. Which finding indicates that the newborn's oxygenation needs are not being met? Select one:

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Naxlex Comprehensive Predictor Exams

Why is it important for the nurse to assess the bladder regularly and encourage the laboring client to void every 2 hours? Select one:

Correct Answer is D

Explanation

The nurse administers vitamin K intramuscularly as prophylaxis to the newborn based on which of the following rationales? Select one:

Correct Answer is D

Explanation

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The nurse assesses a 1-day-old newborn. Which finding indicates that the newborn's oxygenation needs are not being met?
Select one: