The nurse is performing a newborn assessment.
Which symptom, if present in a newborn, would indicate respiratory distress?
Respiratory rate of 50 breaths per minute.
Shallow and irregular respirations.
Flaring of the nares.
Abdominal breathing with synchronous chest movement.
The Correct Answer is C
Choice A rationale
A respiratory rate of 50 breaths per minute is within the normal range for a newborn and does not indicate respiratory distress. Newborns typically have a higher respiratory rate than adults, and this is considered normal.
Choice B rationale
Shallow and irregular respirations can occur in healthy newborns and do not necessarily indicate respiratory distress. It is important to monitor for additional signs of distress before making a definitive assessment.
Choice C rationale
Flaring of the nares is a sign of respiratory distress in newborns as it indicates increased effort to breathe. This symptom is associated with conditions such as respiratory distress syndrome and requires prompt medical evaluation and intervention.
Choice D rationale
Abdominal breathing with synchronous chest movement is normal for newborns as their diaphragm is the primary muscle for respiration. This type of breathing pattern does not indicate respiratory distress and is expected in healthy newborns.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Infusing 1,000 mL normal saline using a large bore IV is a good response to increase the client's blood volume and improve blood pressure, but it should not be the first action. The immediate priority is to relieve the compression of the inferior vena cava caused by the gravid uterus, which is decreasing blood return to the heart and causing hypotension.
Choice B rationale
Obtaining a blood sample for a complete blood count is important for assessing the client's overall health and identifying any possible complications, but it does not address the immediate life-threatening issue of hypotension caused by the gravid uterus compressing the inferior vena cava.
Choice C rationale
Tilting the backboard sideways to displace the uterus laterally is the correct first action. This maneuver helps to relieve the compression of the inferior vena cava by the gravid uterus, thereby improving blood return to the heart, increasing cardiac output, and normalizing blood pressure.
Choice D rationale
Palpating the abdomen for contractions is important to assess for potential labor or uterine irritability, but it does not address the immediate need to relieve the compression of the inferior vena cava causing hypotension.
Correct Answer is B
Explanation
Choice A rationale
Latanoprost eye drops are used to reduce intraocular pressure in glaucoma patients and are not relevant for a newborn exposed to Neisseria gonorrhoeae.
Choice B rationale
Erythromycin ointment is the correct medication to administer to a newborn exposed to Neisseria gonorrhoeae. It is used to prevent ophthalmia neonatorum, an eye infection caused by the bacteria. Administering erythromycin ointment is essential to protect the newborn's eyes from potential blindness or severe infection.
Choice C rationale
Tetracaine eye drops are a topical anesthetic used to numb the eyes during procedures and are not indicated for preventing neonatal eye infections caused by Neisseria gonorrhoeae.
Choice D rationale
Neomycin ointment is an antibiotic used for treating bacterial infections, but it is not the standard treatment for preventing ophthalmia neonatorum in newborns exposed to Neisseria gonorrhoeae. Erythromycin ointment is the recommended prophylactic treatment. .
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