Following a vaginal delivery, the nurse places the neonate under the radiant warmer to elicit spontaneous respirations.

The newborn has a heart rate of 100 beats per minute and remains apneic when the nurse flicks the soles of the feet.

Which action should the nurse implement next?

Give blow-by oxygen via cannula.

Start IV infusion in a scalp vein.

Assist neonatologist with intubation.

Provide positive pressure ventilation.

Answer and Explanation

The Correct Answer is D

Choice A rationale

Blow-by oxygen delivery can provide some additional oxygen to the apneic newborn, but it may not be effective in stimulating breathing or providing adequate ventilation. It is a less direct method of addressing apnea compared to positive pressure ventilation.

Choice B rationale

Starting an IV infusion in a scalp vein is important for medication administration or fluid resuscitation but is not the immediate priority for a newborn who is apneic and has a heart rate of 100 beats per minute. Establishing adequate ventilation takes precedence to ensure oxygenation and stabilize the newborn.

Choice C rationale

Assisting the neonatologist with intubation may be necessary if positive pressure ventilation is unsuccessful or if there are signs of severe respiratory distress. However, the immediate next step for an apneic newborn with a heart rate of 100 beats per minute should be to provide positive pressure ventilation to stimulate breathing.

Choice D rationale

Providing positive pressure ventilation is the recommended immediate action for a newborn who remains apneic and has a heart rate of less than 100 beats per minute. This intervention helps to inflate the lungs, establish effective breathing, and improve oxygenation, which is critical for the newborn's survival.

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Correct Answer is A

Explanation

Choice A rationale

A sore throat, often due to Streptococcus pyogenes, is a significant precursor to acute rheumatic fever. The body’s immune response to the infection can attack its own tissues, leading to rheumatic heart disease if untreated.

Choice B rationale

Influenza is a viral infection and does not typically lead to acute rheumatic fever. While it can cause significant illness, its mechanism and sequelae are unrelated to those of rheumatic fever.

Choice C rationale

Chickenpox, caused by the varicella-zoster virus, presents with distinct symptoms like a vesicular rash and is not linked to rheumatic fever. It primarily affects the skin and nervous system, not the heart.

Choice D rationale

Mumps, a viral infection, mainly impacts the salivary glands and sometimes the pancreas and testes but is not associated with rheumatic fever. Its pathology differs from the immune-mediated damage seen in rheumatic fever.

A. Report the findings immediately to the healthcare provider. B. Obtain a swab of secretions from the penis and urethra. C. Provide the adolescent with a urinal for urinary hesitancy. D. Collect a sterile urine sample for culture and sensitivity.

Correct Answer is A

Explanation

Choice A rationale

Reporting the findings immediately to the healthcare provider is crucial in this scenario. Intense testicular pain with erythema and swelling can indicate testicular torsion, which is a medical emergency requiring prompt surgical intervention to preserve testicular function. Delays in treatment can result in loss of the affected testicle.

Choice B rationale

Obtaining a swab of secretions from the penis and urethra is not the immediate priority in this situation. While it can be important for diagnosing infections, the acute nature of the symptoms suggests a more urgent condition, such as testicular torsion, which needs immediate attention from a healthcare provider.

Choice C rationale

Providing the adolescent with a urinal for urinary hesitancy does not address the immediate concern of intense pain and significant swelling. The symptoms suggest a possible emergency, and addressing urinary hesitancy can wait until after more urgent conditions are ruled out or treated.

Choice D rationale

Collecting a sterile urine sample for culture and sensitivity is not the immediate priority. While it might be useful for diagnosing infections, the symptoms of intense pain, erythema, and swelling in the testicular area suggest an urgent condition like testicular torsion, which requires immediate evaluation and treatment.

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Following a vaginal delivery, the nurse places the neonate under the radiant warmer to elicit spontaneous respirations. The newborn has a heart rate of 100 beats per minute and remains apneic when the nurse flicks the soles of the feet. Which action should the nurse implement next?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A 7-year-old child is admitted to the hospital with a diagnosis of acute rheumatic fever. In obtaining a health history from the child's mother, the recent occurrence of which illness is most significant?

Correct Answer is A

Explanation

A male adolescent arrives at the clinic and reports intense pain in the testicular area that occurred during football practice at high school. The nurse observes the scrotum and identifies significant erythema and swelling. Which action should the nurse take?

Correct Answer is A

Explanation

A client who is in labor states, "I think my water just broke!" The nurse notes that the umbilical cord is on the perineum. Which action should the nurse perform first?

A client at 6-weeks gestation presents to the office with a report of vaginal bleeding for the last 12 hours without cramping. Which action should the nurse take?

The nurse is caring for an infant admitted with dehydration, irritability, signs of extreme hunger, and a palpable olive-like mass in the upper right abdominal quadrant. When feeding the infant, the nurse should monitor for which development?

Following a vaginal delivery, the nurse places the neonate under the radiant warmer to elicit spontaneous respirations. The newborn has a heart rate of 100 beats per minute and remains apneic when the nurse flicks the soles of the feet. Which action should the nurse implement next?

Following a vaginal delivery, the nurse places the neonate under the radiant warmer to elicit spontaneous respirations.

The newborn has a heart rate of 100 beats per minute and remains apneic when the nurse flicks the soles of the feet.

Which action should the nurse implement next?