A newborn with a respiratory rate of 40 breaths/minute at 1 minute after birth is demonstrating cyanosis of the hands and feet.
Which action should the nurse take?
Rub the infant's back.
Assess bowel sounds.
Assist with intubation.
Continue to monitor.
The Correct Answer is D
Choice A rationale
Rubbing the infant's back provides tactile stimulation, which can encourage deeper breaths and a more vigorous cry, aiding in the transition to extrauterine life. While this is a valid intervention for a sluggish infant, it may not be necessary if the respiratory rate is already within the normal range of 30-60 breaths/minute. Cyanosis of the hands and feet (acrocyanosis) is a common, benign finding.
Choice B rationale
Assessing bowel sounds is part of a comprehensive newborn assessment but is not a priority in a situation where the nurse is evaluating respiratory status and color. Bowel sounds provide information about gastrointestinal function and are not directly related to the infant's oxygenation or transition to extrauterine life. This assessment would be performed after ensuring adequate cardiorespiratory function.
Choice C rationale
Intubation is an invasive procedure reserved for infants who are not breathing or have severe respiratory distress, such as a respiratory rate below 30 breaths/minute or persistent central cyanosis. A respiratory rate of 40 breaths/minute is within the normal range for a newborn, indicating adequate respiratory effort. Therefore, intubation is not warranted at this time.
Choice D rationale
Acrocyanosis, or cyanosis of the hands and feet, is a normal physiological finding in the first 24 hours of life due to immature peripheral circulation. The infant's respiratory rate of 40 breaths/minute is within the expected range for a newborn (30-60 breaths/minute). The combination of a normal respiratory rate and benign acrocyanosis indicates the infant is transitioning normally, and continued monitoring is the appropriate action.
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Naxlex Comprehensive Predictor Exams
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Correct Answer is B
Explanation
Choice A rationale
Weighing and measuring the newborn is a routine procedure to establish baseline data. However, it is not the most critical intervention in this scenario given the signs of neurological irritability and instability. While important, it does not address the underlying potential cause of the newborn's symptoms.
Choice B rationale
The newborn's symptoms of tremulousness, tachycardia, and hypertension are classic signs of neonatal abstinence syndrome, often associated with in-utero drug exposure, specifically cocaine. Cocaine is a potent CNS stimulant. Obtaining a drug screen is essential to confirm the diagnosis and guide appropriate medical management and supportive care.
Choice C rationale
Assessing neonatal reflexes is a standard part of a neurological assessment. However, the signs of CNS hyperexcitability like tremulousness are already evident. While a good general practice, it is not the most critical action to identify the underlying cause of the severe symptoms and to begin the correct treatment.
Choice D rationale
A gestational age assessment is a standard part of a newborn's physical examination. It helps in classifying the newborn as term, preterm, or post-term. However, the most immediate priority is to identify the cause of the newborn's distress and instability, which is likely related to drug exposure, not gestational age.
Correct Answer is D
Explanation
Choice A rationale
The direction and volume of blood flow through a VSD depend on the size of the defect and the pressure difference between the ventricles. A small VSD typically has a left-to-right shunt due to higher systemic pressure. This flow pattern does not typically cause valvular dysfunction, but rather increases pulmonary blood flow.
Choice B rationale
Small VSDs often do not require surgical intervention because they are hemodynamically insignificant and may close on their own. Surgical repair is generally reserved for large, symptomatic VSDs that cause congestive heart failure, pulmonary hypertension, or failure to thrive.
Choice C rationale
The prognosis following surgical repair of a VSD is generally excellent, with a low mortality rate. The outcome is highly dependent on the child's preoperative status, and most children have normal lives after successful repair.
Choice D rationale
Spontaneous closure of small muscular VSDs is a well-documented phenomenon. The closure is often attributed to muscular trabeculae growth and the formation of fibrous tissue around the defect. The likelihood of closure decreases with age.
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