The nurse is assessing a newborn at 1 hour of age. Which finding requires the nurse's immediate action?

Pauses in respiration lasting 30 seconds

Respiratory rate 36, crackles present bilaterally

Apical heart rate of 160 with mild systolic murmur heard

Small white papules on nose and chin

Answer and Explanation

The Correct Answer is B

A) Pauses in respiration lasting 30 seconds:
Pauses lasting longer than 20 seconds or accompanied by other signs of distress would warrant further evaluation. A 30-second pause by itself, without additional concerning symptoms, is generally not a reason for immediate action.

B) Respiratory rate 36, crackles present bilaterally:
The presence of bilateral crackles is concerning. Crackles can indicate fluid in the lungs, possibly from retained amniotic fluid or respiratory distress syndrome (RDS). In a term newborn, bilateral crackles at this time, especially if accompanied by tachypnea or other signs of respiratory distress, may indicate a serious respiratory issue, such as aspiration pneumonia or RDS. Immediate assessment and intervention are necessary to ensure the infant is breathing adequately and that there are no underlying complications.

C) Apical heart rate of 160 with mild systolic murmur heard:
An apical heart rate of 160 is within the normal range for a newborn (typically 120-160 bpm). A mild systolic murmur is also not uncommon in newborns and may be benign, especially in the first few days of life. Murmurs are often transient and can be caused by normal circulatory changes as the newborn's cardiovascular system adjusts after birth. Although a heart murmur should be monitored, it is not typically an urgent concern unless associated with signs of poor perfusion or other cardiac symptoms.

D) Small white papules on nose and chin:
These small white papules are likely milia, which are common and harmless in newborns. Milia are keratin-filled cysts that typically appear on the face, especially around the nose and chin. They are a normal finding and resolve on their own without treatment. These papules do not require immediate action.

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Correct Answer is A

Explanation

A) Bacteria that synthesize vitamin K are not present in the newborn's intestinal tract:
Newborns are born with a sterile gastrointestinal tract, meaning they do not yet have the intestinal bacteria necessary to synthesize vitamin K. Vitamin K is essential for the activation of clotting factors, and without sufficient vitamin K, newborns are at risk for bleeding disorders, particularly a condition known as vitamin K deficiency bleeding (VKDB). Administering vitamin K by injection shortly after birth ensures the baby has adequate levels to prevent bleeding.
B) Vitamin K prevents the synthesis of prothrombin in the liver and must be given by injection:
This statement is incorrect. Vitamin K does not prevent the synthesis of prothrombin; rather, it is essential for the liver to synthesize clotting factors, including prothrombin. The injection of vitamin K in newborns is necessary to provide adequate levels of vitamin K to support proper blood clotting, as newborns cannot produce enough on their own at birth due to the absence of gut bacteria that normally produce it.

C) The supply of vitamin K is inadequate for at least 12 months, and the newborn must be supplemented throughout infancy:
While it is true that newborns have a limited supply of vitamin K at birth, this deficiency is typically addressed with a single injection given shortly after birth. Supplementing vitamin K throughout infancy is generally not required, as the infant's gastrointestinal tract will start to develop the necessary bacteria to synthesize vitamin K within the first few weeks to months of life. The first dose of vitamin K prevents bleeding disorders, and in most cases, additional supplementation is not necessary.

D) Most mothers have a diet deficient in vitamin K, which results in the infant being deficient:
While maternal diet does play a role in the newborn's initial vitamin K levels, it is not the primary reason for the deficiency. Vitamin K deficiency in newborns is primarily due to the lack of gut bacteria necessary to produce it, rather than maternal diet. The practice of administering vitamin K to all newborns ensures that they receive adequate levels to prevent bleeding, regardless of maternal dietary intake.

A. Soft, nontender, colostrum is present. B. Swollen, warm, and tender upon palpation. C. Leakage of milk at let-down. At let-down D. A few blisters and bruise on each areola.

Correct Answer is B

Explanation

A) Soft, nontender, colostrum is present:
In the early postpartum period, specifically on day 1, the woman is still in the process of transitioning from producing colostrum (a thick, yellowish fluid rich in antibodies) to mature breast milk. The colostrum may be present, but the breasts are typically not soft and nontender. Instead, they are more likely to be swollen and tender as the milk production ramps up. Therefore, this is not the typical finding on day 1 postpartum.
B) Swollen, warm, and tender upon palpation:
This is the expected finding on day 1 postpartum, especially for a primiparous woman. After childbirth, the breasts begin the transition from producing colostrum to mature breast milk. The increased blood flow and milk production cause the breasts to become swollen, warm, and tender to the touch. This condition is often referred to as engorgement, which is common within the first few days after delivery, particularly in breastfeeding mothers. Engorgement usually peaks around day 3 but may begin to occur slightly earlier, as the body adjusts to milk production.

C) Leakage of milk at let-down:
This finding is more typical of a woman who is further along in the postpartum period, usually after her milk has transitioned from colostrum to mature milk. Milk let-down and the associated leakage typically occur later, often after a few days (around day 3 or later). On day 1, the milk supply is still establishing itself, and leakage is less common.

D) A few blisters and bruises on each areola:
Blisters and bruises on the areola could indicate improper latch or trauma from breastfeeding. This is not a typical or expected finding in a woman who is only 1 day postpartum. If this occurs, the nurse should assess the infant’s latch and the breastfeeding technique to prevent further complications. Such findings should be addressed promptly, but they are not considered normal on day 1.

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The nurse is assessing a newborn at 1 hour of age. Which finding requires the nurse's immediate action?

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Naxlex Comprehensive Predictor Exams

The nurse administers vitamin K to the newborn for what reason?

Correct Answer is A

Explanation

As part of the postpartum assessment, the nurse examines the breasts of a primiparous (first baby) breastfeeding woman who is 1 day postpartum. Which of the following findings should the nurse anticipate?

Correct Answer is B

Explanation

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