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 irregular.

The newborn's respiratory rate is 32/min.

The newborn's pulse oximetry is 91%.

The newborn is beginning to cough.

Answer and Explanation

The Correct Answer is D

The correct answer is **d. The newborn is beginning to cough**.

Choice A rationale:

An irregular respiratory rate in a newborn is not necessarily an indication for nasopharyngeal suctioning. Irregular respirations can have various causes, and suctioning may not be the appropriate intervention.

Choice B rationale:

A respiratory rate of 32 breaths per minute is within the normal range for a newborn and does not indicate the need for nasopharyngeal suctioning.

Choice C rationale:

A pulse oximetry reading of 91% is low and may indicate the need for intervention, but it does not specifically indicate the need for nasopharyngeal suctioning. Other interventions, such as supplemental oxygen, may be more appropriate.

Choice D rationale:

The newborn beginning to cough is a clear indication that there may be secretions or obstruction in the nasopharynx, and suctioning may be necessary to clear the airway and improve respiratory function.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A rationale:
The incompetent cervix is not related to the client's current situation. An incompetent cervix refers to a weakened cervix that may result in premature dilation during pregnancy, leading to potential pregnancy loss or preterm birth. It is not relevant to the client's current stage of labour and cervical dilation.

Choice B rationale:
Postpartum haemorrhage is the correct condition to be concerned about in this situation. The client is 80% effaced and 8 cm dilated, which indicates she is in active labour. These signs of progress indicate that she is at risk for excessive bleeding after delivery, which is known as postpartum haemorrhage.

Choice C rationale:
An ectopic pregnancy occurs when a fertilized egg implants outside the uterus, typically in the fallopian tube. This condition is not related to the client's current presentation, as she is already in active labour.

Choice D rationale:
Hyperemesis gravidarum is severe and persistent nausea and vomiting during pregnancy, usually during the first trimester. This condition is not relevant to the client's current situation, which involves active labour and cervical dilation.

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

Correct Answer is C

Explanation

Choice A rationale:
Limiting the length of breastfeeding to 5 minutes per breast may not address the underlying issue of sore nipples and can compromise the newborn's nutritional intake and bonding with the mother.

Choice B rationale:
Offering supplemental formula between feedings is not indicated unless there are specific concerns about the newborn's weight gain or nutritional needs. It does not directly address the issue of sore nipples.

Choice C rationale:
Assessing the newborn's latch while breastfeeding is essential to identify if improper latch or positioning is causing sore nipples. Correcting the latch technique can alleviate the discomfort and promote effective breastfeeding.

Choice D rationale:
Instructing the client to wait 4 hours between daytime feedings may lead to inadequate feeding for the newborn, especially during the early postpartum period when frequent feedings are essential for establishing breastfeeding and ensuring proper milk supply.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is admitting a client to the birthing unit who reports her contractions started 1 hr ago. The nurse determines the client is 80% effaced and 8 cm dilated. The nurse realizes that the client is at risk for which of the following conditions?

Correct Answer is B

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 C

Explanation

A nurse is providing teaching to a client about the purpose of her upcoming indirect Coombs' test. Which of the following statements should the nurse include in the teaching?

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?

A nurse is reviewing the medical records of four clients who have an acid-base imbalance. The nurse should recognize that which of the following clients is at risk for respiratory alkalosis?

A nurse on an antepartum unit is receiving change-of-shift report for four clients. Which of the following clients should the nurse assess first?

A nurse is assessing a newborn whose mother had gestational diabetes mellitus. The nurse should monitor for which of the following findings as a manifestation of hypoglycemia?

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?

A nurse is reviewing the medical record for a client who is receiving treatment for gestational diabetes mellitus. Which of the following medications should the nurse expect to administer?