A nurse is evaluating a newborn who was born 2 hours ago and was admitted to the neonatal intensive care unit with chest wall retractions and blue discoloration of the hands and feet.

Which finding indicates a decline in the newborn’s status?

Oxygen saturation of 89%

Nasal flaring

Fine crackles

Apneic episode less than 15 seconds

Answer and Explanation

The Correct Answer is A

Choice A rationale
An oxygen saturation of 89% in a newborn who was born 2 hours ago and was admitted to the neonatal intensive care unit with chest wall retractions and blue discoloration of the hands and feet indicates a decline in the newborn’s status. This level of oxygen saturation is below the normal range for a newborn, which is typically above 95%10111213. This could indicate that the newborn is not getting enough oxygen, which could be due to a variety of conditions, including respiratory distress syndrome.
Choice B rationale
Nasal flaring is a sign of respiratory distress in a newborn. However, it is a nonspecific sign and does not necessarily indicate a decline in the newborn’s status. It could be a normal response to the newborn’s efforts to breathe more effectively.
Choice C rationale
Fine crackles can be a sign of a lung condition in a newborn. However, they are a nonspecific sign and do not necessarily indicate a decline in the newborn’s status. They could be a normal finding in a newborn who was born 2 hours ago.
Choice D rationale
An apneic episode less than 15 seconds in a newborn who was born 2 hours ago is not necessarily indicative of a decline in the newborn’s status. Brief periods of apnea (pauses in breathing) are common in newborns and are usually not a cause for concern unless they last longer than 20 seconds or are associated with other signs of distress.

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Correct Answer is A

Explanation

Choice A rationale
Providing the client with a cool sitz bath can help soothe the perineal area, reduce inflammation, and promote healing after a fourth-degree laceration.
Choice B rationale
Administering methylergonovine IM is typically used for the prevention and treatment of postpartum or post-abortion hemorrhage caused by uterine atony or subinvolution. It would not directly address the care of a fourth-degree perineal laceration.
Choice C rationale
Applying a moist, warm compress to the perineum can provide some relief from discomfort, but a cool compress or sitz bath is typically recommended initially after a perineal laceration to help reduce swelling.
Choice D rationale
Applying povidone-iodine to the client’s perineum after she voids is not typically part of the care for a fourth-degree perineal laceration. The area should be kept clean, but routine application of antiseptics is not usually necessary.

A. Glucose level B. Head assessment finding sclera color C. Respiratory rate D. Intake and output

Correct Answer is D

Explanation

Choice A rationale
While monitoring glucose levels is important in newborn care, it is not specifically related to breastfeeding frequency and voiding patterns.
Choice B rationale
While assessing the newborn’s head and sclera color is part of a comprehensive newborn examination, it is not specifically related to breastfeeding frequency and voiding patterns.
Choice C rationale
While monitoring the newborn’s respiratory rate is crucial in newborn care, it is not specifically related to breastfeeding frequency and voiding patterns.
Choice D rationale
Monitoring intake and output is directly related to breastfeeding frequency and voiding patterns. A newborn who has been breastfeeding 3 to 4 times per day should have passed meconium stool by 36 hours old. The absence of meconium stool could indicate a problem and should be reported to the provider.

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A nurse is evaluating a newborn who was born 2 hours ago and was admitted to the neonatal intensive care unit with chest wall retractions and blue discoloration of the hands and feet. Which finding indicates a decline in the newborn’s status?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is 12 hr postpartum and has a fourth-degree laceration of the perineum. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

Correct Answer is D

Explanation

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A nurse is evaluating a newborn who was born 2 hours ago and was admitted to the neonatal intensive care unit with chest wall retractions and blue discoloration of the hands and feet.

Which finding indicates a decline in the newborn’s status?