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

Answer and Explanation

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.

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Free Nursing Study Resources

Correct Answer is C,A,B,D,E

Explanation

C. Instruct the client to empty their bladder.

A. Position the client supine with knees flexed and place a small rolled towel under one of their hips.
B. Palpate the fetal part positioned in the fundus.

D. Palpate the fetal parts along both sides of the uterus.

E. Palpate the fetal part positioned above the symphysis pubis.

A. Have the client limit the length of breastfeeding to 5 min per breast. B. Instruct the client to wait 4 hr between daytime feedings. C. Offer supplemental formula between the newborn's feedings. D. Assess the newborn's latch while breastfeeding.

Correct Answer is D

Explanation

Rationale:

A. Limiting the length of breastfeeding to 5 minutes per breast is not recommended and may lead to inadequate milk transfer and supply issues.

B. Instructing the client to wait 4 hours between daytime feedings may result in insufficient milk intake for the newborn and could impact breastfeeding success.

C. Offering supplemental formula between feedings may interfere with establishing breastfeeding and could decrease the client's milk supply.

D. Assessing the newborn's latch while breastfeeding is the appropriate action for addressing sore nipples. Poor latch is a common cause of nipple soreness in breastfeeding mothers. Ensuring the newborn has a proper latch can help alleviate discomfort and prevent further nipple trauma.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

31. A nurse is preparing to perform Leopold maneuvers on a client who is at 36 weeks of gestation. Identify the sequence of actions the nurse should take. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps)

Correct Answer is C,A,B,D,E

Explanation

A nurse is caring for a client who is 1 day postpartum and breastfeeding her newborn. The client reports sore nipples. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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