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 A
Explanation
Choice A rationale:
Vibroacoustic stimulation is an appropriate action to perform during a nonstress test if there are no fetal heart rate accelerations. It involves using sound or vibration to stimulate the fetus, potentially eliciting the desired heart rate accelerations.
Choice B rationale:
Placing the client in the Trendelenburg position is not indicated in this situation. It may not benefit the fetus and is not a standard intervention for nonreactive nonstress test results.
Choice C rationale:
Conducting a vaginal exam is not relevant to the situation described in the question. A nonreactive nonstress test does not require a vaginal exam.
Choice D rationale:
Collecting a specimen for an indirect Coombs test is not necessary for this scenario. The test result would not provide information relevant to the nonreactive nonstress test.
Correct Answer is D
Explanation
Choice A rationale:
The nurse does not need to obtain a sample of the discharge for laboratory testing at this point. Yellow discharge after circumcision is common and generally not a cause for immediate concern. Laboratory testing is not necessary for routine circumcision care.
Choice B rationale:
Applying povidone-iodine solution twice daily to the circumcision site is not recommended in this situation. Povidone-iodine may cause irritation and delay the natural healing process.
Generally, no specific cleaning solution is required for circumcision care unless otherwise indicated by a healthcare provider.
Choice C rationale:
Wiping the discharge away gently with a washcloth and warm water for the next 48 hours is not the most appropriate action. The circumcision site should be kept clean and dry, but actively wiping away the discharge may cause irritation and disrupt the natural healing process.
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