A mother asks, "Why does my infant have blue hands?".
He is just cold.
He may have been born with a heart problem.
The hands are always blue in a newborn.
The circulation in his hands is not fully developed.
The Correct Answer is D
Choice A rationale:
"He is just cold”. is not the correct choice. While newborns can have cold hands and feet due to their immature thermoregulation, it would not explain persistent blue hands.
Choice B rationale:
"He may have been born with a heart problem”. is not the correct choice as it suggests a congenital heart defect. While cyanosis (bluish discoloration) can be associated with some heart problems, the hands alone being blue is less likely to be solely related to a heart issue.
Choice C rationale:
"The hands are always blue in a newborn”. is not the correct choice. While newborns may have bluish extremities (acrocyanosis) during the first few days after birth due to their developing circulatory system, persistent blue hands beyond this period would require further assessment.
Choice D rationale:
The correct choice is that "The circulation in his hands is not fully developed.”. Newborns have a developing circulatory system, and sometimes, their peripheral circulation takes some time to mature, leading to transient blue hands. However, if the blue color persists or worsens, it's essential to evaluate for any underlying issues.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
The correct guidance includes giving the newborn sponge baths until the cord stump falls off, which helps to keep the area dry. It is essential to keep the umbilical cord stump clean and dry to prevent infection. Submerging the cord stump in water could increase the risk of infection.
Choice B rationale:
Covering the cord with the diaper is not advisable. The diaper could trap moisture around the cord stump, leading to a higher risk of infection. The cord stump should be exposed to air as much as possible to aid in drying and healing.
Choice C rationale:
Washing the cord with mild soap and water is not necessary and could introduce moisture, which should be avoided. Instead, the stump should be cleaned gently with a soft, dry cloth if it gets dirty.
Choice D rationale:
Wrapping the cord in petroleum jelly gauze is not a recommended practice. Applying petroleum jelly or other substances to the cord stump can interfere with the drying process and increase the risk of bacterial growth, leading to infection.
Correct Answer is ["A","B","D"]
Explanation
Choice A rationale:
The normal temperature range for a newborn measured axillary (armpit) is 97.7-99.3°F (36.5- 37.4°C). This is a crucial vital sign to monitor, as any significant deviation from this range could indicate an underlying issue requiring further evaluation.
Choice B rationale:
The newborn's heart rate varies with their activity level. While asleep, it is around 100 bpm, and when awake, it is 120-160 bpm. During crying or agitation, it can go up to 180 bpm.
Monitoring the heart rate is essential, as any abnormal values might indicate cardiac or other health problems.
Choice D rationale:
The normal respiratory rate for a newborn is 30-60 breaths per minute. Respiratory rate is a critical parameter to monitor as rapid or slow breathing could be a sign of respiratory distress or other respiratory conditions.
Choice C rationale:
Blood pressure is not routinely assessed in newborns, as it is challenging to obtain accurate readings due to their small size and physiology. Instead, other vital signs are relied upon for assessment.
Choice E rationale:
The head circumference is not included in the normal vital sign ranges. However, monitoring head circumference is crucial during infancy to track brain growth and development.
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