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

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. Insert a Foley catheter with a urimeter to monitor hourly output: This is a reasonable intervention because magnesium sulfate can affect renal function, and monitoring urinary output is essential. However, there's a more critical intervention to consider first.

B. Have calcium gluconate immediately available: This is the highest priority. Magnesium sulfate toxicity can lead to neuromuscular blockade, and calcium gluconate is the antidote. Having it readily available is crucial in case signs of magnesium toxicity (such as loss of deep tendon reflexes) appear.

C. Provide a quiet environment with subdued lighting: While maintaining a calm environment is generally important for clients on magnesium sulfate, it is not the highest priority in this situation.

D. Assess deep tendon reflexes (DTRs) every 4 hours: This is an important part of monitoring for magnesium sulfate toxicity. However, the immediate availability of calcium gluconate is the highest priority in case toxicity occurs.

A. Avoid alcohol, caffeine, and smoking. B. Eliminate between meal snacks C. Practice relaxation techniques when the nausea first begins D. Increase intake of fluids to 3 quarts daily

Correct Answer is C

Explanation

A. Avoid alcohol, caffeine, and smoking: This is generally good advice during pregnancy to promote a healthy environment for the developing fetus, but it may not specifically address nausea.

B. Eliminate between meal snacks: While this might be suggested for some individuals, keeping something light on the stomach, like crackers, can sometimes help alleviate nausea.

C. Practice relaxation techniques when the nausea first begins: Relaxation techniques, such as deep breathing or meditation, can be beneficial in managing nausea, especially if stress or anxiety contributes to the symptoms.

D. Increase intake of fluids to 3 quarts daily: Staying hydrated is important during pregnancy, but drinking too much fluid at once might not necessarily alleviate nausea and could potentially make it worse.

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The nurse is performing a newborn assessment. Which symptom, if present in a newborn, would indicate respiratory distress?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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