A nurse is assessing a newborn.
Which finding may indicate a problem?
The newborn’s nostrils flare slightly during respiration.
The newborn’s hands and feet are blue and feel cool.
The newborn’s eyes move randomly when his head is turned to the side.
The newborn’s tongue thrusts forward when it is lightly touched.
The Correct Answer is A
The correct answer is choice A. The newborn’s nostrils flare slightly during respiration. This is a sign of respiratory distress in a newborn.
Flaring nostrils indicate that the newborn is working hard to breathe and may not be getting enough oxygen.
Choice B is wrong because the newborn’s hands and feet are blue and feel cool. This is a normal finding called acrocyanosis, which occurs due to immature peripheral circulation.
It usually resolves within 24 to 48 hours after birth.
Choice C is wrong because the newborn’s eyes move randomly when his head is turned to the side. This is a normal finding called nystagmus, which occurs due to immature eye muscles and coordination.
It usually disappears by 6 months of age.
Choice D is wrong because the newborn’s tongue thrusts forward when it is lightly touched. This is a normal finding called the extrusion reflex, which helps the newborn to suck and swallow.
It usually fades by 4 months of age.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is choice C. Assess the client’s blood pressure.Methylergonovine is a uterotonic medication that can cause hypertension and is contraindicated for clients with preeclampsia or cardiac disease.
Therefore, the nurse should check the client’s blood pressure before administering this medication to ensure it is within normal range (120/80 mm Hg or lower).
Choice A is wrong because assessing the client’s pain scale is not a priority assessment before giving methylergonovine.
Pain is not a contraindication for this medication and does not affect its effectiveness.
Choice B is wrong because assessing the client’s respiratory rate is not a priority assessment before giving methylergonovine.
Respiratory rate is not affected by this medication and does not indicate any adverse effects.
Choice D is wrong because assessing the client’s last bowel movement is not a priority assessment before giving methylergonovine.
Bowel movement is not related to postpartum hemorrhage or uterine atony, which are the indications for this medication.
Correct Answer is D
Explanation
The correct answer is choice D: “This test is used to identify fetal abnormalities.” Alpha-fetoprotein (AFP) is a protein produced by the fetus that can be measured in the mother’s blood.
Abnormal levels of AFP may indicate a problem with the development of the baby’s brain, spine, or other organs.
This test is usually done between 15 and 20 weeks of gestation.
Choice A is wrong because AFP does not measure the baby’s maturity.
It is not related to the gestational age or the lung development of the fetus.
Choice B is wrong because AFP is not a routine test for all pregnant women over thirty years of age.
It is an optional screening test that may be offered to women who have a higher risk of having a baby with a birth defect, such as those who have a family history, a previous affected pregnancy, or certain ethnic backgrounds.
Choice C is wrong because AFP is not recommended for people with a history of infertility.
It does not assess the fertility status of the mother or the father.
It only measures the level of a fetal protein in the mother’s blood.
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