A nurse is caring for four newborns.
Which of the following newborns should the nurse assess first?
A newborn who has subconjunctival hemorrhage of the left eye.
A newborn who has rust-stained urine.
A newborn who has nasal flaring.
A newborn who has overlapping suture lines.
The Correct Answer is C
Choice A rationale
Subconjunctival hemorrhage is a common, generally benign finding in newborns, often resulting from increased intraocular pressure during the birthing process, causing rupture of superficial capillaries in the sclera. It presents as a bright red patch under the conjunctiva and usually resolves spontaneously within a few weeks without intervention, thus it does not warrant immediate, priority assessment.
Choice B rationale
Rust-stained urine, or pink-tinged urine, in a newborn is typically due to the presence of uric acid crystals (urates) in the urine, a normal finding related to concentrated urine and the immaturity of the newborn kidney's ability to concentrate urine fully. This is a common, non-pathological observation in the first few days of life, indicating mild dehydration, but it is not an acute, high-priority concern.
Choice C rationale
Nasal flaring is a significant sign of respiratory distress in a newborn, indicating the infant is attempting to increase the diameter of the nasal passages to decrease airway resistance and enhance the intake of oxygen. This compensatory mechanism suggests compromised gas exchange and potential hypoxemia, requiring immediate assessment and intervention to prevent further respiratory compromise.
Choice D rationale
Overlapping suture lines, also known as molding, occurs when the cranial bones shift and overlap during passage through the narrow birth canal. This is a normal, expected finding, especially after a vaginal delivery, and the shape of the head typically returns to normal within a few days to a week, posing no immediate threat to the newborn.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Fundal massage is the primary intervention for uterine atony and postpartum hemorrhage to stimulate uterine contraction and tamponade bleeding. However, an amniotic fluid embolism (AFE) is characterized by sudden cardiopulmonary collapse, hypoxia, and coagulopathy, where fundal massage is irrelevant to the underlying pathology.
Choice B rationale
AFE involves the sudden entry of amniotic fluid into the maternal circulation, triggering a massive anaphylactoid reaction, acute respiratory distress, and severe refractory hypotension, leading to cardiac and respiratory arrest. Initiating cardiopulmonary resuscitation (CPR) is often immediately required to support life functions.
Choice C rationale
Assisting the client to empty their bladder may be beneficial during labor to allow the fetal head to descend, but it is not a priority intervention for the life-threatening, acute physiological crisis of an AFE. The immediate focus must be on optimizing oxygenation, circulation, and treating the underlying shock and coagulopathy.
Choice D rationale
AFE causes severe pulmonary vasoconstriction and acute respiratory distress, leading to profound hypoxemia. Applying oxygen at 2 L/min via nasal cannula is insufficient for this level of respiratory compromise; the client requires high-flow oxygen, often nonrebreather mask or mechanical ventilation, to maintain adequate arterial oxygen saturation.
Correct Answer is ["A","B","C"]
Explanation
Choice A rationale: Calcium gluconate must be readily available whenever magnesium sulfate is administered because it serves as the antidote for magnesium toxicity. Magnesium sulfate depresses neuromuscular transmission and the central nervous system, which can lead to respiratory depression, hypotension, and cardiac arrest if serum levels become excessive. Having calcium gluconate on hand allows for immediate reversal of these life-threatening effects. This is a critical safety measure and therefore a required nursing action.
Choice B rationale: Respiratory status must be assessed at least every hour during magnesium sulfate therapy because respiratory depression is a primary sign of magnesium toxicity. Normal adult respiratory rate is 12 to 20 breaths per minute, and a rate below 12/min is concerning. Magnesium depresses the respiratory center in the medulla, and early recognition of hypoventilation is essential to prevent hypoxia and arrest. Thus, frequent respiratory monitoring is a priority nursing action.
Choice C rationale: Monitoring intake and output is essential because magnesium sulfate is excreted almost entirely by the kidneys. Oliguria, defined as urine output less than 30 mL/hr, increases the risk of magnesium accumulation and toxicity. Careful fluid balance assessment ensures adequate renal clearance and helps prevent complications such as pulmonary edema. Therefore, strict I&O monitoring is a critical nursing responsibility during magnesium sulfate therapy to ensure safe drug metabolism and excretion.
Choice D rationale: Intermittent fetal monitoring is not appropriate in this context. Magnesium sulfate administration and preterm labor with rupture of membranes require continuous fetal monitoring to detect early signs of distress. Intermittent monitoring risks missing decelerations or prolonged bradycardia. Continuous monitoring provides real-time assessment of fetal well-being and is the standard of care in high-risk obstetric situations. Therefore, intermittent monitoring is not a correct action and should not be selected.
Choice E rationale: Supine positioning is contraindicated in pregnancy, especially in the third trimester, because the gravid uterus compresses the inferior vena cava, leading to supine hypotensive syndrome. This decreases venous return, cardiac output, and uteroplacental perfusion, compromising both maternal and fetal oxygenation. The correct position is left lateral recumbent to optimize circulation. Therefore, placing the client supine is unsafe and not an appropriate nursing action in this scenario.
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