A mother of a preterm baby is performing skin-to-skin contact in the neonatal nursery. Which of the following responses would the nurse evaluate as a positive neonatal outcome?
Respiratory rate of 75.
Temperature of 96.5°F.
Sucking or licking of mother’s nipples.
Flaring of the baby’s nares.
The Correct Answer is C
Choice A rationale
A respiratory rate of 75 breaths per minute exceeds the normal range of 30 to 60 breaths per minute in neonates. Tachypnea indicates distress, which necessitates immediate intervention to prevent complications.
Choice B rationale
A temperature of 96.5°F is below the normal neonatal range of 97.7°F to 99.5°F, suggesting hypothermia. This can impair enzyme activity, oxygen delivery, and thermoregulatory functions, requiring prompt warming measures.
Choice C rationale
Sucking or licking of the nipples reflects a positive response in kangaroo care, indicative of improved thermoregulation and bonding. This natural behavior also suggests a healthy neonate capable of initiating feeding.
Choice D rationale
Nasal flaring is a sign of respiratory distress, typically indicating increased effort to meet oxygen demands. This would not be considered a positive outcome and requires immediate evaluation and intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Surgical intervention is not the initial step for uterine atony as conservative measures, such as fundal massage, are prioritized to encourage uterine contraction and reduce bleeding.
Choice B rationale
Fundal massage stimulates uterine contraction by mechanically compressing the myometrium, which helps to constrict the spiral arteries and reduce hemorrhage caused by uterine atony.
Choice C rationale
Establishing venous access is critical for fluid resuscitation but does not directly address the underlying cause of hemorrhage, which requires mechanical or pharmacological uterine contraction.
Choice D rationale
Catheterizing the bladder can prevent displacement of the uterus but does not directly address uterine atony. An empty bladder supports fundal massage by allowing proper uterine positioning.
Correct Answer is A
Explanation
Choice A rationale
Surfactant reduces alveolar surface tension, improving lung compliance and facilitating gas exchange of oxygen and carbon dioxide, critical in addressing respiratory distress syndrome in premature infants.
Choice B rationale
Periodic apnea in premature infants is a neurological immaturity issue, not directly addressed by surfactant, which targets alveolar function in the lungs.
Choice C rationale
Surfactant does not possess antimicrobial properties; it functions to stabilize alveoli, not to combat respiratory infections.
Choice D rationale
Sedation requirements for infants are unrelated to surfactant therapy, which works mechanically in the lungs rather than through central nervous system effects.
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