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

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.

A. Avoid caffeinated drinks for 24 hours before conducting the kick test. B. Exercise for 15 minutes before starting the counting to help increase fetal movement. C. Count the movements once daily, for one hour, before breakfast. D. If 10 kicks are not felt within one hour, drink orange juice and count for another hour.

Correct Answer is D

Explanation

Choice A rationale

Avoiding caffeinated drinks for 24 hours before conducting the kick test is not necessary. Caffeine does not significantly affect fetal movements.

Choice B rationale

Exercising for 15 minutes before starting the counting to help increase fetal movement is not a standard recommendation. While physical activity can sometimes stimulate fetal movement, it’s not a requirement for performing kick counts.

Choice C rationale

Counting the movements once daily, for one hour, before breakfast is not the standard recommendation. The best time to do kick counts is when the baby is usually most active, which might be after a meal, early in the morning, or at another point in the day.

Choice D rationale

If 10 kicks are not felt within one hour, drinking orange juice and counting for another hour is a common recommendation. The sugar in the juice can sometimes stimulate the baby to move. However, if the mother still doesn’t feel 10 movements within 2 hours, she should contact her healthcare provider.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

During the newborn admission assessment, the nurse palpates the newborn’s scrotum and does not feel the testicles. Which assessment technique should the nurse perform next to verify the absence of testes?

Correct Answer is C

Explanation

A pregnant woman is learning how to perform kick (fetal movement) counts. What should the nurse instruct her to do?

Correct Answer is D

Explanation

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