A nurse is caring for a newborn immediately after delivery.
Which of the following would indicate the newborn is showing signs of respiratory distress?
Loud cry.
Grunting.
Rooting.
Acrocyanosis.
The Correct Answer is B
Choice A rationale
A loud cry is a normal sign in a newborn and indicates good lung function and adequate oxygenation. It is not a sign of respiratory distress.
Choice B rationale
Grunting is a sign of respiratory distress in newborns. It indicates that the infant is using extra effort to keep the airways open and improve oxygenation.
Choice C rationale
Rooting is a normal reflex in newborns and is not indicative of respiratory distress. It involves the infant turning their head towards a stimulus when the cheek or mouth is touched.
Choice D rationale
Acrocyanosis refers to the bluish discoloration of the hands and feet in newborns. It is typically a normal finding and not a sign of respiratory distress.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Fetal polydactyly is the presence of extra fingers or toes. This condition does not affect the progress of labor or lead to dystocia, as it doesn't impact the size, position, or descent of the fetus through the birth canal.
Choice B rationale
The occiput anterior cephalic position is the ideal fetal position for labor. It allows the widest part of the fetal head to fit through the pelvis most easily, reducing the likelihood of labor dystocia.
Choice C rationale
An estimated fetal weight of 4600 grams (macrosomia) can lead to labor dystocia. A larger fetus may have difficulty passing through the maternal pelvis, causing obstructed labor.
Choice D rationale
Fetal hydronephrosis refers to the swelling of the kidney due to urine buildup. While this can be a significant health concern, it does not typically impact the labor process directly.
Correct Answer is C
Explanation
Choice A rationale
Preparing the client for an urgent cesarean section is not immediately necessary unless there are signs of fetal distress or other complications. Hypotonic uterine contractions may be managed with medical interventions to stimulate labor.
Choice B rationale
Discussing the client's gynecoid-shaped pelvis is irrelevant to the immediate management of hypotonic uterine contractions. While pelvic shape can influence labor, the focus should be on addressing the uterine contractions.
Choice C rationale
Amniotomy, or artificial rupture of membranes, can help to increase the strength and frequency of contractions in clients with hypotonic uterine contractions. This intervention can stimulate labor progress.
Choice D rationale
Keeping the client on bedrest is not a primary intervention for hypotonic uterine contractions. Encouraging activity and medical interventions to enhance contractions are more appropriate.
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