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.

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Correct Answer is C

Explanation

Choice A rationale:
Preterm gestational age is not indicated by the presence of breast tissue with a flat areola and no bud. Preterm newborns may have immature breast tissue, but it does not manifest as a flat areola with no bud.

Choice B rationale:
Decreased maternal hormones during pregnancy would result in less developed breast tissue in the newborn, but it wouldn't present as a flat areola with no bud. Instead, the breast tissue may be small and less pronounced.

Choice C rationale:
Congenital anomaly refers to a birth defect or malformation that occurs during fetal development. In this case, the flat areola with no bud suggests an abnormality in the development of the breast tissue. Further assessment and evaluation may be required to determine the exact nature of the anomaly.

Choice D rationale:
Ambiguous secondary sex characteristics would involve the presence of characteristics that are not clearly male or female. The described breast tissue does not fit this category, as it is specifically described as having a flat areola with no bud, which is more indicative of a congenital anomaly.
Question 65.

A. "You should begin performing Kegel exercises 6 to 7 weeks after delivery.". B. "You don't need to use birth control if you are exclusively breastfeeding.". C. "You can expect your breasts to be firm and tender 3 to 5 days after delivery.". D. "Your bleeding will remain bright red for the next 6 to 8 weeks.".

Correct Answer is C

Explanation

Choice A rationale:

The nurse should not include the information about beginning Kegel exercises 6 to 7 weeks after delivery because Kegel exercises are pelvic floor exercises that help improve bladder control and should be started earlier, immediately after childbirth. Delaying the exercises for 6 to 7 weeks could result in weaker pelvic floor muscles and potentially exacerbate postpartum urinary issues.

Choice B rationale:

The nurse should not include the information that the client doesn't need to use birth control if exclusively breastfeeding. While exclusive breastfeeding can provide some natural contraceptive effect, it is not a reliable method, and there is still a risk of pregnancy during the postpartum period. The nurse should advise the client to use appropriate birth control methods to prevent unintended pregnancies.

Choice C rationale:

This is the correct answer. The nurse should include information about the client's breasts becoming firm and tender 3 to 5 days after delivery. This is a normal physiological response known as engorgement, which occurs as the breasts prepare for breastfeeding.

Choice D rationale:

The nurse should not inform the client that her bleeding will remain bright red for the next 6 to 8 weeks. While some postpartum bleeding is normal (known as lochia), the color and amount of bleeding change over time. Initially, it is bright red and gradually transitions to a lighter color over the following weeks.

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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 performing an assessment for a newborn and notes breast tissue that has a flat areola with no bud. The nurse should identify that this finding indicates which of the following conditions?

Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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