A nurse is assessing a newborn who is 12 hr old. Which of the following manifestations requires intervention by the nurse?

Acrocyanosis of the extremities

Murmur at the left sternal border

Substernal chest retractions while sleeping

Positive Babinski reflex

Answer and Explanation

The Correct Answer is C

The correct answer is C.

A. Acrocyanosis of the extremities: Acrocyanosis, or blueness of the extremities, is a common finding in newborns and is usually considered normal. It often resolves on its own and doesn't typically require intervention.

B. Murmur at the left sternal border: It's not uncommon for newborns to have innocent murmurs, and many resolve on their own as the infant grows. A murmur at the left sternal border alone may not necessarily indicate a problem, but it should be assessed by a healthcare provider.

C. Substernal chest retractions while sleeping: Chest retractions can be a sign of respiratory distress, and intervention is needed to assess and address the cause. Substernal retractions suggest increased work of breathing and may indicate a respiratory issue that requires attention.

D. Positive Babinski reflex: The Babinski reflex is a normal neurological response in infants. It involves the toes fanning out when the sole of the foot is stroked. A positive Babinski reflex is expected in a 12-hour-old newborn and does not require intervention.

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Correct Answer is A

Explanation

a.Panting helps to control the urge to push and can slow down the delivery, which is important to prevent rapid delivery that could cause injury to both the mother and the baby. It allows the nurse or healthcare provider to better manage the delivery process.

b.Slow-paced breathing is often used during early labor to help manage pain and anxiety. However, when the baby’s head is crowning, panting is more effective in controlling the urge to push and slowing down the delivery process.

c.While deep cleansing breaths can be helpful during contractions to manage pain and focus, they are not as effective as panting in controlling the urge to push during the crowning phase.

d.While it might seem natural to encourage pushing when the baby’s head is crowning, it’s important to control the delivery to prevent rapid birth, which can cause injury to both the mother and the baby. Encouraging the mother to pant helps slow down the process, allowing for a more controlled and safer delivery.

A. Shortness of breath B. Breakthrough bleeding C. Vomiting D. Breast tenderness

Correct Answer is A

Explanation

The correct answer is A.

A. Shortness of breath: Shortness of breath can be a serious side effect of combined oral contraceptives (COCs) and may indicate a potential risk of a blood clot or other cardiovascular issues. It is crucial for the client to seek medical attention promptly if experiencing shortness of breath.

B. Breakthrough bleeding: Breakthrough bleeding is a common side effect of COCs, especially during the first few months of use. While it can be bothersome, it is generally not considered a serious adverse effect. However, the healthcare provider may need to adjust the dosage or type of contraceptive if breakthrough bleeding persists.

C. Vomiting: Vomiting can decrease the absorption of COCs, and if vomiting occurs within a few hours after taking the pill, a backup form of contraception may be needed. However, it is not necessarily an adverse effect that requires immediate notification unless it leads to an inability to take the medication consistently.

D. Breast tenderness: Breast tenderness is a common side effect of hormonal contraceptives and is generally not considered a serious adverse effect. Clients are often advised to monitor for changes in breast tenderness, but it does not require immediate notification.

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A nurse is assessing a newborn who is 12 hr old. Which of the following manifestations requires intervention by the nurse?

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