A nurse in a newborn nursery is receiving a change-of-shift report for four newborns. Which of the following newborns should the nurse assess first?
A newborn who has a short frenulum and is having difficulty breastfeeding
A newborn who is 24 hr old and has not had a meconium stool
A newborn who is 30 hr old and has blood-tinged discharge in her diaper
A newborn who is 10 hr old and has new onset tachypnea
The Correct Answer is D
The newborn who is 10 hr old and has new onset tachypnea should be assessed first as this could indicate a respiratory distress, which requires immediate intervention. The other options are concerning but not as urgent as respiratory distress.
A newborn with a short frenulum and difficulty breastfeeding can be assessed after the respiratory distress is addressed.
A newborn who is 24 hr old and has not had a meconium stool should be assessed for bowel sounds and abdominal distension, but it is not as urgent as respiratory distress. A newborn who is 30 hr old and has blood-tinged discharge in her diaper can be assessed after the respiratory distress is addressed. The blood-tinged discharge could be due to the infant's mother passing her own vaginal blood to the infant or a minor vaginal laceration during delivery.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The nonstress test is a screening tool that assesses fetal well-being. It is performed by monitoring the fetal heart rate (FHR) and uterine contractions (UC) while the client is at rest. The test is considered reactive if there are two or more accelerations of the FHR that reach a certain level above the baseline and last for at least 15 seconds over a 20-min period.
The presence of irregular contractions that are not felt by the client is a finding that is concerning because it could be a sign of uterine hyperstimulation, which can lead to fetal distress. Further diagnostic testing may be needed to assess fetal well-being in this situation.
Option A indicates that the client felt fetal movements during the testing period. This is a reassuring finding because fetal movements are a sign of fetal well-being.
Option B indicates that there were no late decelerations in the FHR with uterine contractions. This is a reassuring finding because late decelerations are a sign of fetal compromise.
Option C indicates that there was an acceleration of the FHR in response to fetal movement. This is a reassuring finding because it indicates that the fetus is capable of responding to stimuli.
Correct Answer is A
Explanation
Cytomegalovirus (CMV) is a common viral infection that can be transmitted from mother to newborn during childbirth. It can also be transmitted through contact with infected bodily fluids, including saliva, urine, and breast milk. Therefore, it is important to practice good hand hygiene and avoid sharing utensils or cups with young children who may be infected. Airborne precautions are not required for CMV, as it is not transmitted through the air. Prophylactic treatment with acyclovir is not effective against CMV, and there is no cure for the infection. Lesions are not typically visible on the mother's genitalia, and many mothers who are infected with CMV have no symptoms at all.
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