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. Caloric intake should be 300 calories above the suggested non-pregnant caloric intake.This is because women with gestational diabetes need to meet the nutritional needs of pregnancy and also control their blood glucose levels.
Choice A is wrong because carbohydrates should make up about 45% of the total dietary intake for women with gestational diabetes, not 25%.
Carbohydrates are important for providing energy and nutrients for the mother and the baby.
Choice B is wrong because animal protein can be included in the pre-bedtime snack as long as it is combined with some carbohydrates.
Protein can help prevent low blood glucose levels during the night.
Choice D is wrong because sugar substitutes do not help to control blood glucose levels.They may also have adverse effects on the baby’s development.Women with gestational diabetes should limit their intake of added sugars and choose foods with natural sugars instead.
Correct Answer is A
Explanation
The correct answer is choice A. The patient uses the sitz bath three times a day.This indicates that the patient understands the benefits of sitz baths for postpartum recovery, such as pain relief, increased blood flow, relaxation, cleansing, and itch relief.Sitz baths can be done with warm or cool water, depending on the preference of the patient.However, they should not be done for more than 20 minutes at a time, as this can cause the stitches in the perineal area to fall apart.
Therefore, choice C is wrong.Choice B is also wrong, as there is no evidence that alternating between warm and cool sitz baths has any additional benefits or effects.
Choice D is wrong, as tightening and relaxing the perineal muscles during a sitz bath is not recommended.This can cause more pain and irritation to the area, and interfere with the healing process.The normal ranges for sitz baths are two to four times a day for up to 20 minutes each.
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