A nurse is caring for a newborn in the neonatal unit following delivery.
Complete the following sentence by using the list of options.
The nurse should further evaluate
The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C"}
The nurse should further evaluate respiratory characteristics and muscle tone to determine if the newborn is experiencing a complication.
Rationale for correct answers
Respiratory characteristics are critical to assess because irregular and shallow breathing in a newborn can indicate neurological or respiratory dysfunction. Normal neonatal respiratory rate ranges from 30 to 60 breaths per minute with regular pattern; deviations may signal distress or central nervous system issues. Muscle tone evaluation is essential since increased tone with tremors suggests possible neurologic irritability or withdrawal. Normal newborn muscle tone should be moderate, neither hypotonic nor hypertonic, with symmetrical movement. These signs correlate with the high-pitched cry, tremors, and exaggerated reflexes noted, which may indicate neurological complications such as withdrawal syndrome or hypoxic-ischemic encephalopathy.
Rationale for incorrect answers
Heart rate (A) is important but was not reported abnormal; normal neonatal heart rate ranges from 120 to 160 beats per minute and the absence of murmurs suggests no cardiac compromise. Temperature (C) is less urgent as mucous membranes are moist and skin warm and dry, indicating stable thermoregulation; normal newborn temperature is 36.5–37.5°C. Feeding patterns (D) appear adequate with no difficulty reported, making this less immediately concerning.
Rationale for incorrect answers
Moro reflex (A) and Babinski reflex (B) are both present and exaggerated, which may be reactive but less specific for immediate concern than muscle tone abnormalities. Skin color (D) is normal without cyanosis or jaundice, reducing the likelihood of hypoxia or hemolytic issues.
Take home points
- Respiratory pattern irregularities in newborns may indicate neurological or respiratory dysfunction.
- Abnormal muscle tone and tremors are key signs of potential neurological complications.
- Normal heart rate, temperature, feeding, and skin color reduce likelihood of cardiac or systemic illness.
- Reflex exaggeration alone is less specific than muscle tone and respiratory changes for early complication detection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is []
Explanation
Rationale for correct condition
Placenta previa occurs when the placenta partially or completely covers the cervical opening, causing painless bright red vaginal bleeding during the second or third trimester. The client’s presentation of painless vaginal bleeding without contractions or abdominal tenderness supports this diagnosis. Fundal height measuring 27 cm at 28 weeks aligns with normal gestation, and the absence of uterine irritability or pain differentiates it from abruptio placentae. Fetal heart rate of 170/min with minimal variability reflects fetal stress but no immediate decelerations. These features are consistent with placenta previa rather than other causes of bleeding.
Rationale for correct actions
Strict bed rest reduces mechanical disruption of the placenta previa site, minimizing further bleeding risk and improving maternal-fetal oxygenation. Large-bore IV access is essential to rapidly administer fluids or blood products if hemorrhage occurs, maintaining maternal hemodynamic stability. Both actions are critical for managing acute vaginal bleeding while ensuring safety until delivery or further intervention.
Rationale for correct parameters
Monitoring fetal well-being via continuous electronic fetal monitoring detects signs of hypoxia or distress, guiding timely interventions. Tracking vaginal bleeding quantifies blood loss and progression, essential to assess severity and need for transfusion. Both parameters directly evaluate maternal and fetal status during placenta previa management.
Rationale for incorrect conditions
Abruptio placentae involves premature placental separation causing painful bleeding and uterine tenderness, absent here. Chorioamnionitis presents with maternal fever, uterine tenderness, and fetal tachycardia due to infection, none reported. Vasa previa entails fetal vessel rupture causing rapid fetal distress and bleeding; no signs of fetal demise or sudden distress are evident.
Rationale for incorrect actions
Administering pitocin is contraindicated as it may cause contractions worsening bleeding in placenta previa. Methotrexate treats ectopic pregnancy or trophoblastic disease, unrelated here. Vaginal examination risks provoking hemorrhage and is avoided in placenta previa.
Rationale for incorrect parameters
White blood cell count monitors infection, not relevant in this case without fever or leukocytosis. Cervical dilation monitoring is contraindicated due to risk of hemorrhage in placenta previa. Beta-human chorionic gonadotropin levels evaluate pregnancy viability or trophoblastic disease, irrelevant here.
Take home points
- Placenta previa presents as painless bright red bleeding in the third trimester.
- Avoid vaginal examinations to prevent hemorrhage in placenta previa.
- Strict bed rest and IV access are critical management steps.
- Differentiate placenta previa from abruptio placentae by pain and uterine tenderness.
Correct Answer is D
Explanation
Choice A rationale
The specific volume of formula for gavage feeding a newborn, such as 20 mL, depends on the newborn's weight, gestational age, and clinical condition. A blanket recommendation of 20 mL without this individualized assessment is inappropriate and could lead to over or underfeeding, impacting growth and gastrointestinal tolerance.
Choice B rationale
Placing a newborn in a supine position immediately after gavage feedings increases the risk of aspiration, especially for infants with immature swallowing reflexes or reflux. The newborn should be positioned on their right side or semi-Fowler's position to facilitate gastric emptying and minimize aspiration risk.
Choice C rationale
While cluster feeding (multiple feedings close together) is a natural pattern for some breastfed infants, for gavage feeding, regular, scheduled intervals are typically maintained to ensure consistent nutrient delivery and proper digestion, especially in newborns who are medically fragile. Cluster feeding is not a standard gavage feeding practice.
Choice D rationale
Nonnutritive sucking (e.g., pacifier use) during gavage feedings is crucial for promoting oral motor development and associating the feeling of fullness with sucking. This helps prevent oral aversion and prepares the newborn for eventual oral feeding, stimulating gastric secretions and improving digestion.
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