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 C
Explanation
Choice A rationale:
Placing the client in a Trendelenburg position (head down and feet up) is not recommended after a convulsion in a pregnant client. It could potentially compromise blood flow to the brain and fetus. The priority after a convulsion is to ensure the client's airway and oxygenation.
Choice B rationale:
Assisting the client to void might be necessary during the course of care but is not the immediate action needed after a convulsion. The priority is to address airway and oxygenation needs.
Choice C rationale:
Administering oxygen to the client via face mask at 10 L/min is the correct action after the client experiences a convulsion. Eclampsia is a severe complication of preeclampsia, characterized by seizures. Providing oxygen ensures adequate oxygenation to the brain and vital organs during and after the convulsion.
Choice D rationale:
Giving calcium gluconate is not the appropriate action for eclampsia. Calcium gluconate is used to treat hyperkalemia and calcium channel blocker overdose. It does not address the underlying issue of eclampsia or prevent further convulsions. The immediate focus should be on managing the convulsions and ensuring the client's safety and well-being.
Correct Answer is A
Explanation
Choice A rationale:
The Moro reflex, also known as the startle reflex, is elicited by making a loud noise above the newborn, causing them to extend their arms and legs and then bringing them back to the body in a hugging motion. This reflex is a normal developmental response in term newborns.
Choice B rationale:
Touching the newborn's cheek with a finger elicits the rooting reflex, where the newborn turns their head toward the stimulus, searching for a nipple or object to suck. It is a different reflex and not the Moro reflex.
Choice C rationale:
Tapping the newborn's forehead with a finger does not elicit any specific reflex. This action is not related to the Moro reflex.
Choice D rationale:
Turning the newborn's head to one side elicits the asymmetric tonic neck reflex (ATNR), not the Moro reflex. In ATNR, when the head is turned to one side, the arm on that side extends while the opposite arm flexes.
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