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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Correct Answer is D

Explanation

Rationale:

A. Using Naegle’s rule, May 3rd isn’t the correct answer

B. Using Naegle’s rule, May 20th isn’t the correct answer

C. Using Naegle’s rule, May 13th isn’t the correct answer

D. This is the correct answer Using Nägele's Rule:

1. Determine the first day of the last menstrual period (LMP): August 10.

2. Subtract 3 months: August - 3 months = May.

3. Add 7 days: May 10 + 7 days = May 17.

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. C. Instruct the client to empty their bladder. D. Palpate the fetal parts along both sides of the uterus. E. Palpate the fetal part positioned above the symphysis pubis.

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.

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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

A nurse is calculating the estimated date of delivery for a client who reports that the first day of her last menstrual period was August 10. Using Nägele's Rule, which of the following is the client's estimated date of delivery?

Correct Answer is D

Explanation

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

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