A nurse is assessing a newborn 1 hour after birth.
Which of the following respiratory rates is within the expected reference range for a newborn?

110/min.

100/min.

24/min.

60/min.

Answer and Explanation

The Correct Answer is D

Choice D rationale

The normal respiratory rate for a newborn is between 30 to 60 breaths per minute. A rate of 60/min is within this range.

Choice A rationale

A respiratory rate of 110/min is too high for a newborn and may indicate respiratory distress.

Choice B rationale

A respiratory rate of 100/min is also too high for a newborn and may indicate respiratory distress.

Choice C rationale

A respiratory rate of 24/min is too low for a newborn and may indicate respiratory depression.

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Correct Answer is C

Explanation

Choice A rationale

Monitoring blood glucose levels frequently is important for newborns, especially those at risk for hypoglycemia. However, it does not directly prevent jaundice. Jaundice is caused by elevated bilirubin levels, which are not directly related to blood glucose levels.

Choice B rationale

Beginning phototherapy immediately is a treatment for jaundice, not a preventive measure. Phototherapy is used to reduce high bilirubin levels in newborns who already have jaundice.

Choice C rationale

Initiating early feeding is an effective way to prevent jaundice in newborns. Early feeding helps promote regular bowel movements, which aids in the excretion of bilirubin from the body, thereby reducing the risk of jaundice.

Choice D rationale

Preparing for a blood transfusion is a treatment for severe jaundice, not a preventive measure. Blood transfusions are used in cases of extreme hyperbilirubinemia that do not respond to other treatments.

A. “This is erythema toxicum, which is a transient condition.”. B. “A caput succedaneum occurs due to prolonged pressure of the head against the cervix.”. C. “Mongolian spots can be found on the skin of many newborns.”. D. “This is a cephalhematoma, which can occur spontaneously.”. .

Correct Answer is B

Explanation

Choice A rationale

Erythema toxicum is a common, benign rash in newborns but does not cause swelling that crosses suture lines.

Choice B rationale

A caput succedaneum is swelling of the scalp that crosses suture lines and is caused by prolonged pressure on the head during delivery.

Choice C rationale

Mongolian spots are benign, flat, congenital birthmarks with wavy borders and irregular shapes, typically found on the lower back and buttocks, not the head.

Choice D rationale

A cephalhematoma is a collection of blood between the skull bone and its periosteum that does not cross suture lines. .

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A nurse is assessing a newborn 1 hour after birth.Which of the following respiratory rates is within the expected reference range for a newborn?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a newborn 4 hours after birth.Which of the following actions should the nurse include in the plan of care to prevent jaundice?

Correct Answer is C

Explanation

A nurse is caring for a newborn delivered by vaginal birth after 3 hours of pushing.The newborn’s mother asks about the swollen area on her son’s head.After palpation and identification that the swelling does cross the suture line, which of the following is an appropriate response by the nurse?

Correct Answer is B

Explanation

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A nurse is assessing a newborn 1 hour after birth.
Which of the following respiratory rates is within the expected reference range for a newborn?