A nurse is assessing a newborn following a vaginal delivery. Which of the following findings should the nurse report to the provider?
Heart rate 136/min
Nasal flaring
Transient strabismus
Overlapping of sutures
The Correct Answer is B
A. Heart rate 136/min is a normal finding for a newborn. The normal range of heart rate for a newborn is 100 to 160/min.
B. Nasal flaring is an abnormal finding for a newborn. Nasal flaring indicates respiratory distress and may be caused by conditions such as pneumonia, meconium aspiration, or congenital heart defects.
C. Transient strabismus is a normal finding for a newborn. Transient strabismus is a temporary misalignment of the eyes that occurs due to weak eye muscles and poor coordination. It usually resolves by 3 to 6 months of age.
D. Overlapping of sutures is a normal finding for a newborn. Overlapping of sutures is caused by molding of the skull during delivery and allows the head to fit through the birth canal. It usually resolves within a few days after birth.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Incorrect. Organizing the work environment is an important step of the time management process, but it is not the priority. The nurse manager should first identify the activities that need to be done before organizing them.
B. Incorrect. Delegating assigned tasks appropriately is an important step of the time management process, but it is not the priority. The nurse manager should first determine which tasks can be delegated and which ones require their direct involvement before assigning them to others.
C. Correct. Making a list of activities to complete is the priority step of the time management process, as it helps the nurse manager to identify and prioritize their goals and responsibilities.
D. Incorrect. Rewarding yourself for accomplishing goals is an important step of the time management process, but it is not the priority. The nurse manager should first complete the tasks that are essential and urgent before rewarding themselves for their achievements.
Correct Answer is C
Explanation
A. "I'm sure your family does not want you to die." is not a therapeutic response, as it invalidates the client's feelings and imposes the nurse's own assumptions. This choice is incorrect.
B. Why would you believe such things?" is not a therapeutic response, as it sounds judgmental and confrontational, which can increase the client's defensiveness and resistance. This choice is incorrect.
C. "How does this make you feel?" is a therapeutic response, as it encourages the client to express and explore their emotions, which can help to build rapport and trust with the nurse. This choice is correct.
D. "You should talk to your family about your feelings." is not a therapeutic response, as it implies that the client is responsible for resolving their own problems and that their family is willing and able to listen and support them, which may not be true. This choice is incorrect.
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