A nurse is completing a full assessment of a newborn at 4 hours of life.

For each of the assessment findings below, click to specify if this is an expected (normal) newborn finding or an abnormal finding.

Note: each column must have at least one response option selected.

Milia

Barrel-shaped chest

Respiratory rate 66/min

Acrocyanosis present

Polydactyly

Answer and Explanation

The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"B"}}

A. Milia: Expected (normal) finding.

B. Barrel-shaped chest: Expected (normal) finding.

C. Respiratory rate 66/min: Abnormal finding.

D. Acrocyanosis present: Expected (normal) finding.

E. Polydactyly: Abnormal finding.

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Correct Answer is A

Explanation

Choice A rationale

Drying the newborn’s skin thoroughly immediately after birth helps reduce heat loss by evaporation, which is a significant concern as wet skin can cause rapid heat loss.

Choice B rationale

Maintaining ambient room temperature at 24°C (75°F) helps prevent heat loss by convection but does not directly address evaporation.

Choice C rationale

Placing the newborn on a warm surface helps prevent heat loss by conduction but does not address evaporation.

Choice D rationale

Preventing air drafts helps reduce heat loss by convection but does not address evaporation.

A. Flexion of arms. B. Caput succedaneum. C. Heart rate 158 bpm. D. Respiratory rate 66/min. E. Acrocyanosis. F. Subcostal retractions. G. Nasal flaring. H. Grunting.

Correct Answer is ["D","F","G","H"]

Explanation

Choice A rationale

Flexion of arms is a normal finding in newborns and does not indicate respiratory distress.

Choice B rationale

Caput succedaneum is a common condition where the scalp swells due to pressure during delivery. It does not indicate respiratory distress.

Choice C rationale

A heart rate of 158 bpm is within the normal range for newborns and does not indicate respiratory distress.

Choice D rationale

A respiratory rate of 66/min is above the normal range (30-60 breaths per minute) and indicates respiratory distress.

Choice E rationale

Acrocyanosis is common in newborns and does not indicate respiratory distress.

Choice F rationale

Subcostal retractions indicate increased work of breathing and are a sign of respiratory distress.

Choice G rationale

Nasal flaring is a sign of respiratory distress as it indicates increased effort to breathe.

Choice H rationale

Grunting is a sign of respiratory distress as it indicates difficulty in maintaining lung expansion.

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A nurse is completing a full assessment of a newborn at 4 hours of life. For each of the assessment findings below, click to specify if this is an expected (normal) newborn finding or an abnormal finding. Note: each column must have at least one response option selected.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse on the labor and delivery unit is caring for a newborn immediately following birth.Which of the following actions by the nurse caring for the newborn reduces heat loss by evaporation?

Correct Answer is A

Explanation

The nurse is caring for a newborn one hour after delivery.Which of the following assessment findings does the nurse identify as signs of respiratory distress? (Select all that apply)

Correct Answer is ["D","F","G","H"]

Explanation

A nurse is assessing a newborn 1 hour after birth.Which of the following respiratory rates is within the expected reference range for a newborn?

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Which of the following statements accurately describes a characteristic of the newborn immune system?

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A nurse is completing a full assessment of a newborn at 4 hours of life.

For each of the assessment findings below, click to specify if this is an expected (normal) newborn finding or an abnormal finding.

Note: each column must have at least one response option selected.