A nurse is caring for four newborns in a special care nursery.
Which of the following newborn assessment findings requires immediate intervention?
Blue coloring of the hands and feet in an 8-hour-old newborn.
Small raised pearly spots on the newborn's nose.
Apical heart rate of 140 bpm.
Nasal flaring and grunting.
The Correct Answer is D
Choice A rationale
Blue coloring of the hands and feet in an 8-hour-old newborn (acrocyanosis) is a common, benign finding as the newborn’s circulatory system adjusts post-birth. It does not require immediate intervention.
Choice B rationale
Small raised pearly spots on the nose (milia) are harmless and common in newborns. They do not necessitate any intervention.
Choice C rationale
An apical heart rate of 140 bpm is within the normal range for newborns and does not require intervention.
Choice D rationale
Nasal flaring and grunting are signs of respiratory distress in a newborn. This condition demands immediate intervention to ensure the newborn’s airway is clear and breathing is adequately supported.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Elevated WBC count is not typically associated with HELLP syndrome. HELLP syndrome involves hemolysis, elevated liver enzymes, and low platelet count.
Choice B rationale
Elevated platelet count is not a feature of HELLP syndrome. In fact, thrombocytopenia (low platelet count) is a hallmark of the condition.
Choice C rationale
Decreased BUN is not a characteristic of HELLP syndrome. The syndrome primarily affects liver function and platelets.
Choice D rationale
Elevated liver enzymes are a key diagnostic feature of HELLP syndrome, reflecting liver dysfunction and damage, which is part of the condition's pathology. .
Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"C"}
Explanation
Based on the given case, here's why the answer is "Threatened miscarriage" and "Hemorrhagic shock":
Threatened Miscarriage
- Positive pregnancy test: The client has a confirmed intrauterine pregnancy.
- Vaginal bleeding and cramping: The client presents with symptoms commonly associated with threatened miscarriage, such as significant abdominal cramping and moderate bleeding with clots.
- Cervical os closed: In a threatened miscarriage, the cervix remains closed, which is consistent with the physical examination findings.
Hemorrhagic Shock
- Moderate bleeding with clots: The client reports moderate bleeding which, if it continues unchecked, can lead to significant blood loss.
- Severe abdominal cramping: Severe and constant abdominal pain can be associated with heavy bleeding.
- Vital signs: Although the current vital signs are stable, prolonged or heavy bleeding can quickly lead to a drop in blood pressure and other signs of shock.
By recognizing these symptoms and acting promptly, the nurse can help prevent complications such as hemorrhagic shock.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.