Exhibit 1. How can the nurse assess the successful transition of the respiratory system in the newborn? (Select All that Apply.).

Dry the baby thoroughly.

Suctioning the mouth and nose with a bulb syringe to clear mucus.

Observe the chest and abdomen.

Count the number of respirations per minute.

Answer and Explanation

Correct Answer : B,C,D,E

Choice A rationale:

Drying the baby thoroughly is not directly related to assessing the successful transition of the respiratory system. It is essential for warmth and comfort but does not provide specific information about the respiratory system.

Choice B rationale:

Suctioning the mouth and nose with a bulb syringe to clear mucus is important to ensure the airways are clear and the newborn can breathe effectively. This action helps assess the airway patency and successful initiation of breathing.

Choice C rationale:

Observing the chest and abdomen is crucial to assess the respiratory effort and symmetry. Normal chest movements and equal rise and fall of the abdomen indicate a successful transition of the respiratory system.

Choice D rationale:

Counting the number of respirations per minute is essential to determine if the respiratory rate falls within the expected reference range (around 30-60 breaths per minute for a newborn) and if there are any irregularities.

Choice E rationale:

Observing the color of the mucous membranes is important as cyanosis (blue discoloration) may indicate inadequate oxygenation. Pink mucous membranes are a positive sign, indicating a successful transition of the respiratory system.

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Correct Answer is A

Explanation

Choice A rationale:

The correct guidance includes giving the newborn sponge baths until the cord stump falls off, which helps to keep the area dry. It is essential to keep the umbilical cord stump clean and dry to prevent infection. Submerging the cord stump in water could increase the risk of infection.

Choice B rationale:

Covering the cord with the diaper is not advisable. The diaper could trap moisture around the cord stump, leading to a higher risk of infection. The cord stump should be exposed to air as much as possible to aid in drying and healing.

Choice C rationale:

Washing the cord with mild soap and water is not necessary and could introduce moisture, which should be avoided. Instead, the stump should be cleaned gently with a soft, dry cloth if it gets dirty.

Choice D rationale:

Wrapping the cord in petroleum jelly gauze is not a recommended practice. Applying petroleum jelly or other substances to the cord stump can interfere with the drying process and increase the risk of bacterial growth, leading to infection.

A. "This is a Mongolian spot, which is found on many newborns.". B. "This is a caput succedaneum, which is a collection of fluid from pressure of the vacuum extractor.". C. "This is erythema toxicum, which is a transient allergic reaction that causes edema in the skin.". D. "This is a cephalhematoma, which will resolve on its own in 3 to 5 days.".

Correct Answer is B

Explanation

"This is a caput succedaneum, which is a collection of fluid from the pressure of the vacuum extractor.”.

Choice A rationale:

A Mongolian spot is a benign, flat, bluish-gray pigmented area often found on the sacral or gluteal area of some newborns with darker skin tones. It is not related to the swelling on the newborn's head caused by vacuum extraction.

Choice B rationale:

A caput succedaneum is a localized swelling on the baby's scalp that occurs due to pressure from the vacuum extractor during delivery. It is typically soft and may cross the suture lines. This explanation accurately describes the swelling the baby has on his head.

Choice C rationale:

Erythema toxicum is a common rash that appears as small red bumps with white or yellow centers. It is a benign and self-resolving condition that does not cause swelling on the head or involve the suture lines.

Choice D rationale:

A cephalhematoma is a collection of blood between the skull and the periosteum that does not cross the suture lines. It is caused by trauma during birth and may take weeks to months to resolve. This does not match the description of the swelling caused by vacuum extraction.

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Exhibit 1. How can the nurse assess the successful transition of the respiratory system in the newborn? (Select All that Apply.).

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with the parents of a newborn about caring for the umbilical cord stump. Which of the following instructions should the nurse include?

Correct Answer is A

Explanation

A nurse is caring for a newborn who was delivered by vacuum extraction and has swelling on his head that crosses the suture line. The newborn's mother asks about the swelling on her newborn's head. Which of the following responses should the nurse make?

Correct Answer is B

Explanation

A nurse is reinforcing discharge teaching about circumcision care with the parent of a newborn who had a circumcision using the Plastibell device. Which of the following client statements indicates an understanding of the teaching? (Select all that apply.).

A nurse is collecting data from a newborn who is 12 hours old. His respiration rate is 44/min, shallow, with periods of apnea lasting up to 5 seconds. Which of the following actions should the nurse take?

A nurse is collecting data from a newborn 1 hr after delivery. Which of the following respiratory rates is within the expected reference range for a newborn?

A nurse is reinforcing teaching about comfort measures for breast engorgement with a client who is postpartum and is bottle-feeding her newborn. Which of the following statements by the client indicates a need for further teaching?

A nurse is caring for a newborn immediately after birth. Which of the following actions by the nurse reduces evaporative heat loss by the newborn?

The nurse admits a newborn to the admission nursery and prepares to bathe the baby for the first time after assessing which of the following?

A nurse is collecting data from a newborn. Which of the following anatomical landmarks should the nurse use to measure chest circumference?

A mother asks, "Why does my infant have blue hands?".