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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A rationale

External fetal monitors are non-invasive and do not pose a risk of transmitting HIV from mother to baby. They are considered safe for monitoring fetal well-being in an HIV-positive mother.

Choice B rationale

Administering antiviral medication is essential in reducing the risk of mother-to-child transmission of HIV. It's a standard care practice for managing HIV-positive pregnant women.

Choice C rationale

Preparing for a caesarean section may be recommended to reduce the risk of vertical transmission of HIV during delivery, especially if the viral load is high.

Choice D rationale

Internal fetal scalp electrodes are contraindicated because they can create a portal for HIV transmission from mother to baby through small abrasions or punctures on the fetal scalp.

A. Uterine atony. B. Thrombophlebitis. C. Postpartum preeclampsia. D. Retained placental fragments.

Correct Answer is A

Explanation

Choice A rationale

Uterine atony is a common complication following polyhydramnios because the excessive amniotic fluid can lead to uterine overdistension, which in turn can cause poor uterine muscle tone and increased risk of postpartum hemorrhage.

Choice B rationale

Thrombophlebitis is an inflammation of a vein with clot formation, but it is not directly associated with polyhydramnios.

Choice C rationale

Postpartum preeclampsia is high blood pressure and signs of organ damage after delivery, but there is no direct link between polyhydramnios and this condition.

Choice D rationale

Retained placental fragments can lead to postpartum hemorrhage but are not specifically associated with polyhydramnios.

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A nurse is caring for four newborns in a special care nursery.Which of the following newborn assessment findings requires immediate intervention?

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A nurse is caring for four newborns in a special care nursery.
Which of the following newborn assessment findings requires immediate intervention?