The following newborns are three hours old and are sleeping.
The registered nurse should notify the provider about which newborn?
The newborn with a heart rate of 154 beats/minute.
The newborn with a respiratory rate of 72 breaths/minute.
The newborn with a red raised capillary hemangioma on left forearm.
The newborn with whitish, hardened nodules on the gums of the mouth.
The Correct Answer is B
Choice A rationale
A newborn's heart rate typically ranges from 120 to 160 beats/minute. A heart rate of 154 beats/minute falls within this normal physiological range, indicating adequate cardiac function and sympathetic nervous system regulation. This rate efficiently delivers oxygenated blood to developing tissues, supporting the high metabolic demands of a neonate.
Choice B rationale
A newborn's normal respiratory rate is typically 30 to 60 breaths/minute. A rate of 72 breaths/minute indicates tachypnea, which can signify respiratory distress, infection, or other underlying pulmonary or systemic issues. Persistent tachypnea warrants further investigation to prevent potential hypoxemia or respiratory failure.
Choice C rationale
A capillary hemangioma is a benign proliferation of endothelial cells forming a vascular lesion. These "strawberry marks" are common in newborns, often appearing within the first few weeks of life and typically resolving spontaneously. Their presence does not usually indicate an acute medical emergency or require immediate provider notification.
Choice D rationale
Whitish, hardened nodules on the gums of a newborn are commonly known as Epstein pearls or Bohn's nodules. These are benign, keratin-filled cysts that are normal developmental findings. They are remnants of the dental lamina and typically disappear within a few weeks or months without intervention, causing no discomfort to the infant.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
The client thanking the nurse for the information indicates politeness but does not confirm that the client has processed the information or intends to act upon it. This response is superficial and does not provide insight into the client's understanding or commitment to a safety plan.
Choice B rationale
The client explaining they are not planning to leave their home indicates a potential barrier to safety and does not demonstrate engagement with a safety plan. While the client may not be ready to leave, this response shows a lack of immediate actionable steps regarding the provided resources and safety measures.
Choice C rationale
The client thinking their home will be safer now that there is a baby in the house is a dangerous misconception. The presence of a child does not guarantee safety and can sometimes escalate violence. This response suggests a lack of realistic assessment of the danger and a misunderstanding of the dynamics of intimate partner violence.
Choice D rationale
The client putting the number of the crisis center into their phone demonstrates a concrete step towards utilizing the resource and engaging with a safety plan. This action indicates an acknowledgment of the potential need for assistance and a proactive measure to access support when needed, signaling an understanding of the information's importance.
Correct Answer is B
Explanation
Choice A rationale
A high-protein, high-calorie diet is crucial for children with cystic fibrosis due to malabsorption caused by pancreatic enzyme insufficiency. Supplementation with high-calorie formulas helps meet their increased metabolic demands and compensate for nutrient losses, supporting growth and development despite the exocrine pancreatic dysfunction.
Choice B rationale
This statement is incorrect. Pancreatic enzymes are essential for individuals with cystic fibrosis because the thick, viscous secretions block the pancreatic ducts, leading to malabsorption of fats, proteins, and fat-soluble vitamins. Even with a good appetite and regular bowel movements, enzyme supplementation is necessary to ensure proper nutrient absorption.
Choice C rationale
Chest physiotherapy (CPT) and postural drainage are vital components of cystic fibrosis management. These techniques help dislodge and clear thick mucus from the airways, reducing the risk of respiratory infections and improving lung function. Performing these therapies multiple times a day is a standard and necessary practice.
Choice D rationale
Regular physical activity, such as playing on swings and running, is beneficial for children with cystic fibrosis. Exercise helps mobilize respiratory secretions, improves lung function, and promotes overall well-being. It is an encouraged and enjoyable aspect of their daily routine, contributing to pulmonary hygiene.
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