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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice D rationale
The normal respiratory rate for a newborn is between 30 to 60 breaths per minute. A rate of 60/min is within this range.
Choice A rationale
A respiratory rate of 110/min is too high for a newborn and may indicate respiratory distress.
Choice B rationale
A respiratory rate of 100/min is also too high for a newborn and may indicate respiratory distress.
Choice C rationale
A respiratory rate of 24/min is too low for a newborn and may indicate respiratory depression.
Correct Answer is B
Explanation
Choice A rationale
Administering only the Hepatitis B vaccine within 1 hour of birth is not sufficient for a newborn born to a Hepatitis B positive mother. The newborn also needs Hepatitis B immunoglobulin (HBIG) to provide immediate passive immunity.
Choice B rationale
Administering both the Hepatitis B vaccine and Hepatitis B immunoglobulin (HBIG) within 12 hours of delivery is the recommended practice for newborns born to Hepatitis B positive mothers. This provides both active and passive immunity.
Choice C rationale
Administering only Hepatitis B immunoglobulin (HBIG) within 12 hours of birth is not sufficient. The newborn also needs the Hepatitis B vaccine to develop long-term immunity.
Choice D rationale
Administering Hepatitis B immunoglobulin (HBIG) within 12 hours, followed by monthly Hepatitis B vaccines for 12 months, is not the standard practice. The newborn should receive the Hepatitis B vaccine series according to the recommended schedule. .
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