A nurse completes a newborn assessment on a 6-hour-old newborn. She notices cyanotic hands and feet. Which action is the nurse's priority?

Administer oxygen.

Place newborn in an isolette.

Apply pulse oximeter.

Swaddle baby in blankets.

Answer and Explanation

The Correct Answer is D

A. Administering oxygen is unnecessary unless central cyanosis (lips and tongue) is present.
B. An isolette may help with thermoregulation, but swaddling is the more immediate action.
C. Pulse oximetry is unnecessary for peripheral cyanosis.
D. Cyanotic hands and feet (acrocyanosis) are normal in the first 24-48 hours after birth due to immature circulation. Keeping the baby warm by swaddling promotes circulation.

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Correct Answer is B

Explanation

A. While concerning, delayed meconium passage can be monitored for a few more hours.
B. Newborns should void within 24 hours of birth. Failure to void may indicate renal issues or dehydration and requires immediate evaluation.
C. A temperature of 37.5° C is within the normal range for a newborn.
D. Acrocyanosis (bluish discoloration of the hands and feet) is normal in the first 24-48 hours after birth and typically resolves without intervention.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}

Explanation

Meconium aspiration syndrome (MAS) occurs when a newborn inhales meconium-stained amniotic fluid during or after delivery, leading to respiratory distress. This newborn has several findings consistent with MAS:

Dark brown-greenish amniotic fluid during labor indicates meconium-stained fluid.

Fine crackles throughout lung fields and expiratory grunting suggest impaired gas exchange and possible airway obstruction.

Rapid and shallow respirations (80/min) and the presence of green-stained vernix and fingernails further support this diagnosis.

Jaundice, hypoglycemia, and cold stress are also potential complications in newborns but are not the most immediate threats based on this newborn's clinical presentation.

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A nurse completes a newborn assessment on a 6-hour-old newborn. She notices cyanotic hands and feet. Which action is the nurse's priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in the newborn nursery is caring for a group of newborns. Which of the following newborns requires immediate intervention?

Correct Answer is B

Explanation

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}

Explanation

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