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: "If I go too long overdue, the amniotic fluid volume can become too low for my baby to be safe." This is a correct answer that indicates that the client understands one of the Reasons for induction of labor at 42 weeks' pregnancy.
Choice B Reason: "My baby took longer to grow, and now she's ready to be born." This is an incorrect answer that shows a misconception about fetal growth and development. Fetal growth does not depend on gestational age alone, but also on genetic, maternal, placental, and environmental factors. A post-term fetus does not necessarily grow faster or larger than a term fetus. In fact, some post-term fetuses may experience intrauterine growth restriction (IUGR), which means slower than expected growth for gestational age.
Choice C Reason: "I don't really need this induction, my baby will come whenever he wants to." This is an incorrect answer that reveals a lack of awareness or acceptance of the need for induction of labor at 42 weeks' pregnancy. Induction of labor is recommended for post-term pregnancies to prevent potential complications such as fetal distress, stillbirth, or maternal hemorrhage.
Choice D Reason: "Since I am so tired of being pregnant, I am being induced." This is an incorrect answer that implies that induction of labor is based on maternal preference or convenience rather than medical indication. Induction of labor should not be done without a valid Reason or informed consent, as it carries some risks such as failed induction, prolonged labor, infection, uterine rupture, or cesarean delivery.
Correct Answer is C
Explanation
Choice A Reason: "It's okay to want a small baby when you're a teen." This is an incorrect answer that validates the patient's misconception and reinforces her unhealthy behavior. It also implies that there is something wrong with having a normal-sized baby or being a teen mother.
Choice B Reason: "You shouldn't be worrying about your figure." This is an incorrect answer that dismisses the patient's feelings and concerns and may make her defensive or resistant to change. It also does not address the underlying issues or provide any guidance or support.
Choice C Reason: ""Your baby needs adequate nutrition to develop and to be healthy." This is because this response provides factual information and education to the patient about the importance of nutrition during pregnancy. It also conveys empathy and concern for both the mother and the baby without being judgmental or accusatory.
Choice D Reason: "You are causing harm to your baby." This is an incorrect answer that blames and criticizes the patient and may make her feel guilty or ashamed. It also does not offer any help or solutions for her situation.
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