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 ["5"]
Explanation
Step 1 is (1000 mcg ÷ 200 mcg/tablet) = 5 tablets. The nurse should administer 5 tablets.
Correct Answer is B
Explanation
Choice A rationale
Surgical intervention is a secondary measure for obstetric hemorrhage and is considered only after initial non-invasive interventions fail to control bleeding, such as fundal massage and uterotonic medications.
Choice B rationale
Fundal massage is the first-line intervention for uterine atony as it stimulates uterine contractions, reducing blood loss by compressing blood vessels at the placental site and promoting hemostasis.
Choice C rationale
Establishing venous access is essential for fluid resuscitation and medication administration but is not the immediate priority compared to fundal massage for controlling active bleeding.
Choice D rationale
Catheterizing the bladder may help assess urinary output and prevent bladder distension, which can impede uterine contraction, but it is not the initial intervention for hemorrhage.
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