A nurse is collecting data from a term newborn who is 12 hr old. Which of the following findings should the nurse report to the provider?

Abdominal breathing

Grunting

Respiratory rate 55/min

Irregular respirations

Answer and Explanation

The Correct Answer is B

A)   Incorrect- Abdominal breathing is a normal pattern in newborns and does not require immediate reporting.
B)   Correct - Grunting is a sign of respiratory distress in a newborn and should be reported to the provider for further evaluation.
C)   Incorrect- A respiratory rate of 55/min is within the normal range for a newborn and does not require immediate reporting.
D)   Incorrect- Irregular respirations are common in newborns and may not necessarily be indicative of a problem.

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Correct Answer is C

Explanation

A) Incorrect- The angle of insertion for the hepatitis B vaccine is typically 90 degrees.

B) Incorrect- Obtaining parental consent is important for any medical procedure involving a minor, but it is not specific to the administration of the hepatitis B vaccine.
C) Correct - The first dose of the hepatitis B vaccine is usually given within the first 24 hours after birth to newborns whose mothers are hepatitis B positive to prevent vertical transmission.
D) Incorrect- The hepatitis B vaccine is usually administered into the vastus lateralis muscle in the newborn's thigh, not the dorsal gluteal muscle.

A. Foul smelling vaginal discharge B. Fetal heart tones 98/min C. Amniotic fluid with meconium noted D. Maternal temperature 38.3* C101)

Correct Answer is B

Explanation

A) Incorrect- Foul-smelling vaginal discharge might indicate infection but is not the priority over the presence of meconium-stained amniotic fluid.
B) Correct- Fetal heart rate is important to monitor, but the presence of meconium- stained amniotic fluid has higher priority. fetal heart tones 98/min, because this indicates fetal distress and requires immediate intervention.
C) Incorrect - Amniotic fluid with meconium noted could indicate fetal hypoxia or distress, but it is not always a sign of a problem and depends on other factors such as gestational age and fetal activity.
D) Incorrect- Maternal temperature elevation might indicate infection but is not the priority over assessing the condition of the amniotic fluid and the baby.

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A nurse is collecting data from a term newborn who is 12 hr old. Which of the following findings should the nurse report to the provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the care of a newborn whose mother has hepatitis B. Which of the following actions should the nurse plan to take when administering the hepatitis B vaccine?

Correct Answer is C

Explanation

A nurse in a provider's office is collecting data from a client who is at 34 weeks of gestation and reports having a sudden gush of vaginal fluid. Which of the following manifestations is the priority?

Correct Answer is B

Explanation

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