A nurse has received a mother and her baby in the postpartum unit. The baby is approximately 2 hours old.
Which of the following is NOT a symptom of transient tachypnea of the newborn?
Heart rate of 170
Grunting or sighing with respirations
Nasal flaring
Respirations of 72
The Correct Answer is A
Choice A rationale
Heart rate of 170. A heart rate of 170 is not a symptom of transient tachypnea of the newborn.
Choice B rationale
Grunting or sighing with respirations. This is a symptom of transient tachypnea of the newborn.
Choice C rationale
Nasal flaring. This is a symptom of transient tachypnea of the newborn.
Choice D rationale
Respirations of 72. This is a symptom of transient tachypnea of the newborn.
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Related Questions
Correct Answer is D
Explanation
Choice A rationale
Perinatal asphyxia refers to a lack of oxygen flow to the fetus around the time of birth. This can lead to multiple organ dysfunction and neurological issues, but it is not a common cause of a newborn being small for gestational age.
Choice B rationale
Preterm delivery can result in a newborn being small for their gestational age simply because they have not had the full amount of time to grow in the womb. However, preterm babies are typically compared to other preterm babies when assessing size, not to full-term babies.
Choice C rationale
Fetal hyperinsulinemia, or an excess of insulin in the fetus, can lead to excessive growth and a larger-than-average baby size (macrosomia), not a smaller size.
Choice D rationale
Placental insufficiency, where the placenta does not work as well as it should, can limit the amount of oxygen and nutrients the fetus receives. This can restrict the baby’s growth, leading to a small size for gestational age.
Correct Answer is C
Explanation
Choice A rationale
While providing age-appropriate stimulation is important for all newborns, it is not the priority nursing goal in caring for a newborn with a myelomeningocele awaiting surgery.
Choice B rationale
Educating the parents about the defect is an important part of care, but it is not the priority nursing goal. The immediate physical needs of the newborn take precedence.
Choice C rationale
This is the correct answer. The sac covering the exposed neural tissue must be carefully protected to prevent infection and further damage. Therefore, maintaining the integrity of the sac is the priority nursing goal.
Choice D rationale
Promoting maternal-infant bonding is important, but it is not the priority nursing goal in caring for a newborn with a myelomeningocele awaiting surgery.
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