The nurse is performing a newborn assessment. Which symptom, if present in a newborn, would indicate respiratory distress?
Flaring of the nares
Shallow and irregular respirations
Respiratory rate of 50 breaths per minute
Abdominal breathing with synchronous chest movement
The Correct Answer is A
A. Flaring of the nares:
Flaring of the nares is a clinical sign of respiratory distress in newborns. It indicates that the infant is working harder to breathe and is attempting to increase the size of the nostrils to get more air.
B. Shallow and irregular respirations:
Shallow and irregular respirations can be a sign of respiratory distress, but flaring of the nares is a more specific and immediate indication.
C. Respiratory rate of 50 breaths per minute:
While a respiratory rate of 50 breaths per minute might be within the normal range for a newborn, the overall clinical picture, including other signs of distress, should be considered.
D. Abdominal breathing with synchronous chest movement:
Abdominal breathing with synchronous chest movement is not a normal pattern for a newborn and could indicate respiratory distress.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Request a return demonstration of a diaper change:While it's useful for parents to know how to change a diaper, feeding is more critical for the infant’s health and development in the early days.
B. Evaluate infant feeding techniques prior to discharge:Ensuring that the parents understand how to properly feed their newborn is crucial. Proper feeding techniques are essential for the infant's nutrition, growth, and development. Issues with feeding can lead to dehydration, weight loss, and other health problems. Therefore, this is the most important intervention.
C. Provide the results of the infant's hearing test to the parents:Sharing the results of the hearing test is important, but it is less immediate compared to ensuring that the infant is properly fed.
D. Ensure that they have the pediatric clinic's phone number:
While it is important for parents to have contact information for follow-up care, it is secondary to ensuring they can feed their baby properly.
Correct Answer is A
Explanation
A. Cries vigorously when stimulated:
Explanation: Vigorous crying is a positive sign in a newborn. It indicates that the baby is responsive, breathing effectively, and is capable of establishing the necessary air exchange.
B. A positive Babinski reflex:
Explanation: The Babinski reflex is a normal reflex in infants where the toes spread out when the sole of the foot is stimulated. While it is a normal reflex in newborns, it might not necessarily indicate the immediate transition to extrauterine life.
C. Heart rate of 220 beats/minute:
Explanation: A heart rate of 220 beats per minute in a newborn is higher than the normal range. It could be a sign of tachycardia, and this finding might require further evaluation by healthcare providers.
D. Flexion of all four extremities:
Explanation: Flexion of extremities is a normal response in a newborn, but it might not specifically indicate successful transition. It's a common response seen in healthy newborns.
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