A nurse is assessing a newborn who is 10 hr old. Which of the following findings should the nurse report to the provider?
Axillary temperature 36.5°C (97.7°F).
Nasal flaring.
Heart rate 158/min.
One void since birth.
The Correct Answer is B
Choice A rationale:
An axillary temperature of 36.5°C (97.7°F) is within the normal range for a newborn. Normal axillary temperature for a newborn is typically between 36.5°C to 37.5°C (97.7°F to 99.5°F).
Choice B rationale:
This is the correct choice. Nasal flaring in a newborn is a concerning sign and may indicate respiratory distress. It suggests that the baby is having difficulty breathing and should be reported to the provider for further evaluation.
Choice C rationale:
A heart rate of 158/min is within the normal range for a newborn. The normal heart rate for a newborn can range from 100 to 160 beats per minute.
Choice D rationale:
Having one void since birth is not a concerning finding for a 10-hour-old newborn. In the early hours of life, the frequency of voids may vary, but the baby should have an increasing number of wet diapers in the following days.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Continuous abdominal pain and vaginal bleeding in a client with a history of cocaine use are indicative of abruptio placentae. Abruptio placentae is a medical emergency where the placenta detaches from the uterine wall before delivery, leading to severe bleeding and abdominal pain. Immediate medical intervention is necessary to prevent complications for both the mother and the baby.
Choice B rationale:
Hydatidiform mole is a gestational trophoblastic disease that occurs due to an abnormal pregnancy. It is not associated with continuous abdominal pain and vaginal bleeding. Instead, clients with this condition often present with vaginal bleeding and a grape-like cluster of cysts in the uterus.
Choice C rationale:
Preterm labor involves regular uterine contractions and cervical changes before 37 weeks of gestation. While preterm labor can cause abdominal discomfort, it is not usually described as continuous abdominal pain. Vaginal bleeding is not a typical symptom of preterm labor.
Choice D rationale:
Placenta previa is a condition where the placenta covers the opening of the cervix. It can cause painless vaginal bleeding, but it is not usually associated with continuous abdominal pain. Clients with placenta previa often experience sudden, painless bleeding later in pregnancy.
Correct Answer is B
Explanation
Choice A rationale:
Hyporeactivity, or reduced responsiveness to stimuli, is not typically associated with neonatal abstinence syndrome (NAS) NAS is characterized by increased irritability and not reduced activity.
Choice B rationale:
An excessive high-pitched cry is a common manifestation of neonatal abstinence syndrome. Infants exposed to substances like methadone during pregnancy may experience heightened sensitivity and exhibit a high-pitched cry as a sign of withdrawal.
Choice C rationale:
Acrocyanosis, a bluish discoloration of the hands and feet, is not a specific indicator of neonatal abstinence syndrome. It is a common finding in newborns and often resolves on its own.
Choice D rationale:
A respiratory rate of 50/min is within the normal range for a newborn. It is not an indication of neonatal abstinence syndrome.
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