During a newborn assessment, which symptom, if present, would indicate respiratory distress?

Shallow and irregular respirations.

Respiratory rate of 50 breaths per minute.

Flaring of the nares.

Abdominal breathing with synchronous chest movement.

Answer and Explanation

The Correct Answer is C

Choice A rationale

While shallow and irregular respirations can be a sign of respiratory distress in newborns, it is not the most indicative symptom. Newborns naturally have irregular breathing patterns, which can include periods of rapid breathing followed by periods of no breathing for up to 10 seconds.

Choice B rationale

A respiratory rate of 50 breaths per minute is within the normal range for a newborn. Newborns typically breathe at a rate of 40 to 60 breaths per minute.

Choice C rationale

Flaring of the nares, or nostrils, is a common sign of respiratory distress in newborns. It indicates that the baby is working hard to breathe.

Choice D rationale

Abdominal breathing with synchronous chest movement is normal in newborns. It is not a sign of respiratory distress.

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Correct Answer is C

Explanation

Choice A rationale

Initiating phototherapy for the newborn is a treatment for jaundice, not a diagnostic step. It would be premature to start this treatment without confirming the diagnosis and assessing the severity of jaundice.

Choice B rationale

Reviewing the mother’s medical records for blood type and Rh factor can be useful in cases where Rh incompatibility is suspected. However, this would not be the immediate next step when observing a yellow tint on the baby’s skin.

Choice C rationale

Measuring bilirubin levels using transcutaneous bilirubinometry is the appropriate next step when jaundice is suspected in a newborn. This non-invasive test can quickly and accurately

measure bilirubin levels, helping to determine the severity of jaundice and guide treatment decisions.

Choice D rationale

Evaluating the results of the cord blood Coomb’s test can help identify cases of immune- mediated hemolytic disease of the newborn, a potential cause of neonatal jaundice. However, this would not typically be the first step taken when jaundice is observed.

A. Measure the size of the scrotal sac for length and width. B. Observe the urethral opening on the surface of the penis when the newborn voids. C. Use a fingertip to palpate the inguinal canal for a weakening or indentation. D. Perform transillumination of the scrotal sac to visualize shadows of the testes.

Correct Answer is C

Explanation

Choice A rationale

Measuring the size of the scrotal sac does not verify the absence of testes.

Choice B rationale

Observing the urethral opening when the newborn voids does not verify the absence of testes.

Choice C rationale

If a testis is not readily identified, a finger sweep should be performed from the anterior iliac crest along the inguinal canal while palpating the scrotum. This is the correct technique to verify the absence of testes.

Choice D rationale

Transillumination of the scrotal sac is not the first step in verifying the absence of testes.

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During a newborn assessment, which symptom, if present, would indicate respiratory distress?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While conducting a daily assessment of a one-day-old newborn, the nurse notices a yellow tint on the baby’s forehead, sternum, and abdomen.What should be the nurse’s next course of action?

Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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