A client expresses concern that her 2-hour-old newborn is sleepy and difficult to awaken. The nurse explains that this behavior indicates:

normal progression of behavior.

probable hypoglycemia.

physiological abnormality.

inadequate oxygenation.

Answer and Explanation

The Correct Answer is A

A. Newborns typically go through predictable behavioral states after birth. During the first period of reactivity, which lasts about 30–60 minutes after birth, the newborn is awake, alert, and active. This is followed by a period of sleep or decreased activity, which can last 2 to 4 hours. It is normal for the baby to be sleepy and difficult to awaken during this phase, especially around 2 hours of age.

B. Probable hypoglycemia could cause lethargy in a newborn, but it would typically be accompanied by other symptoms such as jitteriness, poor feeding, or abnormal vital signs. In a healthy 2-hour-old baby, sleepiness alone is not enough to suggest hypoglycemia.

C. Physiological abnormality is incorrect. There is no evidence of abnormality in a sleepy 2-hour-old newborn, as this is an expected part of the normal behavioral cycle after birth.

D. Inadequate oxygenation would likely present with signs such as cyanosis, abnormal respiratory rate, or poor perfusion, not just sleepiness.

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Correct Answer is D

Explanation

A. Deficient fluid volume is not the priority concern at this time. While newborns are at risk for dehydration, there are no indications in the assessment (such as dry mucous membranes or poor feeding) that would suggest deficient fluid volume as the immediate priority.

B. Risk for infection is a concern for all newborns, especially in the first hours of life. However, the information provided does not suggest signs of infection such as fever, lethargy, or abnormal skin color.

C. Impaired parenting may be a concern later on if the parents show difficulty bonding or caring for the infant. However, this is not the immediate priority based on the infant's current assessment.

D. Hypothermia is the priority. The infant’s axillary temperature of 95.8° F (35.4° C) is below the normal range for a newborn, which is typically between 97.7° F (36.5° C) and 99.5° F (37.5° C). Hypothermia in newborns can lead to complications such as respiratory distress, metabolic instability, and increased risk for infection. Immediate interventions, such as warming the infant and ensuring a warm environment, are necessary to prevent further complications.

A. birth trauma. B. stork bites. C. milia D. Mongolian spots

Correct Answer is D

Explanation

A. Birth trauma typically refers to physical injuries sustained during delivery, such as bruising or fractures. Bluish markings across the lower back are not indicative of birth trauma.
B. Stork bites are reddish or pinkish marks, usually found on the nape of the neck, eyelids, or forehead. They are vascular birthmarks and are not bluish in color.
C. Milia refers to small white cysts found on a newborn's face, usually on the nose, chin, or forehead, caused by blocked sebaceous glands. It is not associated with bluish markings.
D. Mongolian spots are bluish or purplish birthmarks commonly found on the lower back or buttocks of infants, especially those with darker skin. These are normal and typically fade over time.

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A client expresses concern that her 2-hour-old newborn is sleepy and difficult to awaken. The nurse explains that this behavior indicates:

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Naxlex Comprehensive Predictor Exams

When assessing a newborn 1 hour after birth, the nurse measures an axillary temperature of 95.8° F (35.4° C), an apical pulse of 114 beats per minute, and a respiratory rate of 60 breaths per minute. The nurse would identify which area as the priority?

Correct Answer is D

Explanation

During a physical assessment of a newborn, the nurse observes bluish markings across the newborn's lower back. The nurse interprets this finding as:

Correct Answer is D

Explanation

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