The nurse is informed that a newborn infant with Apgar scores of 1 and 4 will be brought to the neonatal intensive care unit (NICU). The nurse determines that which intervention is the priority?

Turning on the apnea and cardiorespiratory monitor.

Connecting the resuscitation bag to oxygen.

Setting up the radiant warmer control temperature at 36.4°C (97.5°F).

Preparing for the insertion of an intravenous (IV) line with D5W.

Answer and Explanation

The Correct Answer is B

Choice A Reason:

Turning on the apnea and cardiorespiratory monitor is important for continuous monitoring of the newborn’s vital signs. However, it is not the immediate priority. The newborn’s low Apgar scores indicate severe distress, and immediate resuscitation efforts are necessary to stabilize the infant.

Choice B Reason:

Connecting the resuscitation bag to oxygen is the priority action. The newborn’s Apgar scores of 1 and 4 suggest significant respiratory and cardiovascular compromise. Providing oxygen and assisting with ventilation are critical to ensure adequate oxygenation and perfusion, which are essential for the infant’s survival.

Choice C Reason:

Setting up the radiant warmer control temperature at 36.4°C (97.5°F) is important for maintaining the newborn’s body temperature. However, this is not the immediate priority. Stabilizing the newborn’s respiratory and cardiovascular status takes precedence over temperature regulation.

Choice D Reason:

Preparing for the insertion of an intravenous (IV) line with D5W is necessary for administering fluids and medications. However, it is not the immediate priority. Ensuring the newborn’s airway, breathing, and circulation are stable is the first step in neonatal resuscitation.

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Correct Answer is C

Explanation

Choice A Reason:

Reddened with a small amount of bloody drainage is a common finding immediately after circumcision. However, this is not the expected appearance after the initial healing phase. The presence of bloody drainage should decrease over time, and the site should begin to show signs of healing.

Choice B Reason:

Pink without drainage is not typical immediately after circumcision. The surgical site will usually be red and may have some drainage as part of the normal healing process. A completely pink and dry site would be expected only after full healing has occurred.

Choice C Reason:

Reddened with a scant amount of yellow exudate is the expected appearance during the healing process. The yellow exudate is part of the normal healing response and should not be mistaken for infection. This exudate typically appears within the first few days after circumcision and indicates that the healing process is progressing normally.

Choice D Reason:

Reddened, with copious blood is not normal and indicates a potential complication. Copious bleeding from the circumcision site requires immediate medical attention as it may suggest an issue with clotting or a problem with the surgical site.

A. 48/min B. 22/min C. 100/min D. 110/min

Correct Answer is A

Explanation

Choice A reason:

A respiratory rate of 48 breaths per minute is within the expected reference range for a newborn. The normal respiratory rate for newborns typically falls between 30 and 60 breaths per minute. This rate ensures that the newborn is receiving adequate oxygen to support their metabolic needs and is a sign of healthy lung function.

Choice B reason:

A respiratory rate of 22 breaths per minute is below the expected reference range for a newborn. Such a low rate may indicate respiratory depression or other underlying issues that require immediate medical attention. Newborns have higher metabolic rates and smaller lung capacities, necessitating a faster breathing rate to meet their oxygen demands.

Choice C reason:

A respiratory rate of 100 breaths per minute is above the expected reference range for a newborn. This condition, known as tachypnea, can be a sign of respiratory distress or other complications such as infection, transient tachypnea of the newborn (TTN), or congenital heart defects. It is essential to monitor and address any causes of elevated respiratory rates to ensure the newborn’s well-being.

Choice D reason:

A respiratory rate of 110 breaths per minute is significantly above the expected reference range for a newborn. This extreme tachypnea is a critical indicator of severe respiratory distress or other serious conditions that require immediate medical intervention. Prompt assessment and treatment are necessary to prevent further complications and ensure the newborn’s health.

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The nurse is informed that a newborn infant with Apgar scores of 1 and 4 will be brought to the neonatal intensive care unit (NICU). The nurse determines that which intervention is the priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A male newborn infant has just been circumcised. The nurse checks the surgical site, expecting it to have what appearance?

Correct Answer is C

Explanation

A nurse is assessing a newborn 1 hour after birth. Which of the following respiratory rates is within the expected reference range for a newborn?

Correct Answer is A

Explanation

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