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 D

Explanation

A. Heart Rate: 108 bpm = 2 points, Respiratory Effort: Regular rate with a cry = 2 points, Muscle Tone: Some flexion = 1 point, Reflex Irritability: Vigorous cry with stimulation = 2 points, Color: Pink body, blue extremities (acrocyanosis) = 1 point: Total APGAR Score: 8
B. A. Heart Rate: 108 bpm = 2 points, Respiratory Effort: Regular rate with a cry = 2 points, Muscle Tone: Some flexion = 1 point, Reflex Irritability: Vigorous cry with stimulation = 2 points, Color: Pink body, blue extremities (acrocyanosis) = 1 point: Total APGAR Score: 8
C. A. Heart Rate: 108 bpm = 2 points, Respiratory Effort: Regular rate with a cry = 2 points, Muscle Tone: Some flexion = 1 point, Reflex Irritability: Vigorous cry with stimulation = 2 points, Color: Pink body, blue extremities (acrocyanosis) = 1 point: Total APGAR Score: 8
D. A. Heart Rate: 108 bpm = 2 points, Respiratory Effort: Regular rate with a cry = 2 points, Muscle Tone: Some flexion = 1 point, Reflex Irritability: Vigorous cry with stimulation = 2 points, Color: Pink body, blue extremities (acrocyanosis) = 1 point: Total APGAR Score: 8

A. "It is not uncommon for circumcision babies to void 36 to 42 hours after the procedure." B. "I can expect the circumcision to be fully-healed in 3 to 5 days." C. "I will apply a lubricant over the circumcision site with each diaper change." D. "I will need to remove the plastibell in 7 to 10 days".

Correct Answer is C

Explanation

A. Newborns should void within 24 hours after the procedure; delays beyond 24 hours require medical attention.

B. Healing usually takes 7-10 days, not 3-5 days.

C. Applying petroleum jelly or another lubricant at each diaper change prevents the diaper from sticking to the healing site, reducing pain and promoting healing.

D. The Plastibell falls off on its own within 5-8 days and should not be forcibly removed.

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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?

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Naxlex Comprehensive Predictor Exams

The nurse notes that a newborn, who is 5 minutes old, exhibits the following characteristics: pink body with blue hands and feet, heart rate 108 bpm. respiratory rate 36 per minute, some flexion, and a vigorous cry with stimulation. What does the nurse determine the baby's APGAR score to be?

Correct Answer is D

Explanation

The nurse is instructing a new parent on appropriate circumcision care. Which statement by the parent demonstrates effective teaching?

Correct Answer is C

Explanation

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