A nurse is assessing a newborn who was born 2 hr ago and was admitted to the neonatal intensive care unit with chest wall retractions and blue discoloration of the hands and feet. Which of the following findings indicates a decline in the newborn's status?
Apneic episode less than 15 seconds
Fine crackles
Oxygen saturation of 89%
Nasal flaring
The Correct Answer is C
Rationale:
A. An apneic episode less than 15 seconds may be considered within normal limits for a newborn and does not necessarily indicate a decline in status.
B. Fine crackles may indicate fluid in the lungs but are not specific to a decline in the newborn's status.
C. An oxygen saturation of 89% indicates hypoxemia, which is a significant concern and suggests respiratory compromise. It indicates a decline in the newborn's status and requires immediate intervention to improve oxygenation.
D. Nasal flaring is a sign of respiratory distress but may not be as concerning as a low oxygen saturation level in this context. It indicates increased work of breathing but does not provide direct information about oxygenation status.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. Gestational diabetes mellitus is not a contraindication for a contraction stress test.
B. A previous classical incision (a vertical uterine incision) increases the risk of uterine rupture during labor, making a contraction stress test contraindicated.
C. A previous stillbirth is not a contraindication for a contraction stress test.
D. A nonreactive nonstress test may indicate the need for further evaluation with a contraction stress test, but it is not a contraindication in itself.
Correct Answer is B
Explanation
Rationale:
A. Allowing the medication to reach room temperature is not a specific requirement for administering a dinoprostone insert.
B. Verifying that informed consent is obtained is essential before administering any medication or procedure to ensure the client understands the risks, benefits, and alternatives.
C. Placing the client in a semi-Fowler's position after administration may not be necessary for the use of a dinoprostone insert.
D. Instructing the client to avoid urinary elimination is not necessary for the administration of a dinoprostone insert.
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