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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is choice **b. Hearing loss**.
Choice A rationale:
Cataracts are not a common finding in newborns with congenital CMV infection. Cataracts are more commonly associated with other congenital infections like rubella, toxoplasmosis, and herpes simplex virus (HSV).
Choice B rationale:
Hearing loss is one of the most common manifestations of congenital CMV infection. Up to 40-58% of infants with symptomatic congenital CMV infection develop sensorineural hearing loss, which can be unilateral or bilateral, and progressive over time.
Choice C rationale:
Macrosomia, or large birth size, is not a typical finding in congenital CMV infection. In fact, infants with symptomatic congenital CMV infection are more likely to be small for gestational age or have intrauterine growth restriction.
Choice D rationale:
Urinary tract infection (UTI) is not a common presentation of congenital CMV infection. CMV can cause inclusion bodies in the urine, but overt UTI is not a typical finding. More common manifestations include petechiae, hepatosplenomegaly, jaundice, and central nervous system involvement.
Correct Answer is B
Explanation
The correct answer is choice B. Single palmar creases.
Choice A rationale:
Rust-stained urine is typically due to urate crystals and is common in newborns. It usually resolves on its own and is not a cause for concern.
Choice B rationale:
Single palmar creases can be associated with certain genetic conditions, such as Down syndrome. This finding should be reported to the provider for further evaluation.
Choice C rationale:
Subconjunctival hemorrhage is a common finding in newborns due to the pressure changes during delivery. It usually resolves without intervention and is not typically a cause for concern.
Choice D rationale:
Transient circumoral cyanosis is often seen in newborns and can occur when the baby is crying or feeding. It usually resolves on its own and is not typically a cause for concern.
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