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 C

Explanation

Choice A Reason:

Placing the client in a supine position for 30 minutes following the first dose of anesthetic solution is not a standard recommendation. The positioning during epidural placement is typically a seated or side-lying position.

Choice B Reason:

Administering 1,000 mL of dextrose 5% in water prior to the first dose of anesthetic solution is not a standard practice for epidural anesthesi

A. Fluids may be administered, but the type and volume depend on the patient's individual needs and the healthcare provider's orders.

Choice C Reason:

Monitoring the client's blood pressure every minute following the first dose of anesthetic solution is appropriate. Epidural anesthesia can potentially cause hypotension (low blood pressure), which is a common side effect. Therefore, close monitoring of the client's blood pressure is crucial, especially following the administration of the initial dose of the anesthetic solution. The goal is to promptly detect and manage any decrease in blood pressure to ensure the well-being of both the mother and the baby.

Choice D Reason:

Ensuring the client has been NPO (nothing by mouth) for 4 hours prior to the placement of the epidural and the first dose of anesthetic solution is not a specific requirement for epidural anesthesi

A. NPO status is more relevant to surgical procedures involving general anesthesia and is not typically a strict requirement for epidural placement.

A. Pressure on the perineum causing the client to bear down B. Expulsion of clear fluid from the vagina C. Continuous contraction lasting 2 min D. Expulsion of a blood-tinged mucous plug

Correct Answer is C

Explanation

The correct answer is C. Continuous contraction lasting 2 min.

A. Pressure on the perineum causing the client to bear down is a common sign in the later stages of labor when the cervix is fully dilated. It is not typically a cause for immediate concern during the admission phase.

B. Expulsion of clear fluid from the vagina may be amniotic fluid, which can indicate rupture of membranes. While important to note, it is not as urgent as a prolonged contraction.

C. Continuous contraction lasting 2 min is a concerning finding and should be reported first.

A contraction lasting 2 minutes is excessively long and may lead to decreased uterine blood flow, affecting fetal oxygenation. It requires prompt attention from the healthcare provider.

D. Expulsion of a blood-tinged mucous plug, also known as the "bloody show," is a common occurrence in early labor and is not as urgent as the prolonged contraction.

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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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