A preterm infant exhibits symptoms including grunting, nasal flaring, and tachypnea. The nurse anticipates the newborn will need which treatment(s)?

Oxygen administration and surfactant administration.

Chest tube insertion and drainage.

Frequent suctioning through an endotracheal tube.

Partial exchange blood transfusion.

Answer and Explanation

The Correct Answer is A

A. The entry of air into the alveoli, replacing expelled amniotic fluid, is a critical mechanical stimulus that initiates the transition to neonatal breathing.
B. Decreased oxygen levels trigger chemical, not mechanical, stimuli.
C. The diaphragm moves downward during inspiration, not upward.
D. Drying and stimulation help initiate breathing through sensory stimulation, not mechanical.

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Correct Answer is C

Explanation

A. Placing the baby under a warmer can be done if skin-to-skin is not effective.

B. CPR is unnecessary as the newborn’s vital signs are within normal limits for this age.

C. Skin-to-skin contact is the best initial intervention to stabilize temperature and promote bonding, which may also regulate respiratory and heart rates.

D. Oxygen is not indicated as the respiratory rate and oxygenation appear adequate.

A. Hemolysis of neonatal red blood cells by the maternal antibodies. B. Delayed meconium excretion resulting in the production of direct bilirubin. C. Pathological liver function resulting from hypoxemia during the birthing process. D. Physiological destruction of fetal red blood cells during the extrauterine period.

Correct Answer is D

Explanation

A. Hemolysis by maternal antibodies suggests hemolytic disease of the newborn (e.g., Rh incompatibility), which typically presents earlier and more severely.
B. Delayed meconium excretion may lead to increased bilirubin, but this is not the most common cause of jaundice at 3 days.
C. Pathological jaundice occurs within the first 24 hours or persists longer than a week.
D. Physiological jaundice is a common finding in newborns due to the natural breakdown of fetal red blood cells (RBCs) and the immature liver's inability to efficiently process bilirubin.

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A preterm infant exhibits symptoms including grunting, nasal flaring, and tachypnea. The nurse anticipates the newborn will need which treatment(s)?

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Naxlex Comprehensive Predictor Exams

The nurse is assessing a 4-hour old newborn. The nurse's findings include an irregular respiratory rate at 58, heart rate of 138 with a regular rhythm, and axillary temperature of 97.4 °F. Based on these assessments which intervention(s) should the nurse perform first?

Correct Answer is C

Explanation

A 3-day-old infant is slightly jaundiced and has an elevated bilirubin level. What is the most probable cause for these changes?

Correct Answer is D

Explanation

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