A nurse is caring for a newborn.
Which of the following assessment findings should indicate to the nurse that suctioning of the nasopharynx is needed?
The newborn's respiratory rate is 32/min.
The newborn's respiratory rate is irregular.
The newborn is beginning to cough.
The newborn's pulse oximetry is 91.
None of the above
The Correct Answer is E
None of the choices provided indicate that suctioning of the nasopharynx is needed for a newborn.
Nasopharyngeal suctioning is performed to remove mucus or saliva from the back of the throat when a newborn is unable to cough or swallow. It is commonly used in infants with bronchiolitis.
Choice A, “The newborn’s respiratory rate is 32/min,” is not an answer because a respiratory rate of 32/min is within the normal range for a newborn.
Choice B, “The newborn’s respiratory rate is irregular,” is not an answer because irregular breathing paterns are common in newborns.
Choice C, “The newborn is beginning to cough,” is not an answer because coughing is a normal reflex that helps clear the airway.
Choice D, “The newborn’s pulse oximetry is 91,” is not an answer because pulse oximetry measures oxygen saturation and does not indicate the need for nasopharyngeal suctioning.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Answer: D
Rationale:
(A) "Your partner will apply continuous, firm pressure between your thumb and index finger": This statement is not appropriate for describing counterpressure during labor. Counterpressure typically involves applying pressure to areas such as the lower back or sacrum, not between the thumb and index finger.
(B) "Your partner will apply pressure to the top of your uterus during contractions": This statement is not appropriate. Applying pressure to the top of the uterus during contractions could be harmful and is not recommended as a counterpressure technique during labor. Counterpressure is generally applied to the lower back or hips to alleviate pain.
(C) "Your partner will apply steady pressure with a tennis ball to your finger": This statement is not correct. Counterpressure during labor involves applying pressure to the lower back or hips, not to the fingers. A tennis ball may be used, but it is applied to the lower back or sacral area, not the fingers.
(D) "Your partner will apply upward pressure on you": This statement is appropriate. During labor, counterpressure is often applied by the partner to the lower back or hips, pressing upward or in a direction that helps alleviate the pain caused by contractions, particularly in cases of back labor. This technique can help relieve discomfort by counteracting the pressure from the baby's head against the mother's spine.
Correct Answer is B
Explanation
If a prolapsed cord is identified, the nurse should perform a vaginal examination and ensure the presenting part is pushed upwards to relieve pressure on the cord.
Choice A) is not correct because while it is important to cover the cord with a sterile saline saturated towel if it has prolapsed externally 1, it is not the next action after calling for assistance and notifying the provider.
Choice C) is not correct because administering oxygen via non-rebreather mask at 8 L/min is not mentioned as an immediate intervention for a prolapsed cord .
Choice D) is not correct because initiating an infusion of IV fluids for the client is not mentioned as an immediate intervention for a prolapsed cord .
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