The nurse assesses a newborn at 36 weeks' gestation, and the following behaviors are noted: nasal ﬂaring, labored breathing, and excessive mucus. The nurse is most concerned about:
Select one:

Possible Meconium Aspiration Syndrome (MAS).

Possible polycythemia.

Possible Transient Tachypnea of the Newborn (TTN).

Possible Respiratory Distress Syndrome (RDS).

Answer and Explanation

The Correct Answer is D

Choice A Reason: Possible Meconium Aspiration Syndrome (MAS). This is an unlikely condition for this newborn, as MAS occurs when fetal stool (meconium) enters into the lungs before or during birth, causing airway obstruction, inﬂammation, and infection. MAS usually aﬀects term or post-term infants who experience fetal distress or hypoxia in utero.

Choice B Reason: Possible polycythemia. This is an unrelated condition for this newborn, as polycythemia refers to an abnormally high number of red blood cells in the blood, which can increase blood viscosity and impair circulation.

Polycythemia may occur in infants who have delayed cord clamping, intrauterine growth restriction, maternal diabetes, or high altitude exposure.

Choice C Reason: Possible Transient Tachypnea of the Newborn (TTN). This is a less serious condition than RDS, as TTN is a mild respiratory problem that results from delayed clearance of fetal lung ﬂuid after birth. TTN causes rapid breathing, nasal ﬂaring, grunting, and mild cyanosis. It usually resolves within 24 to 48 hours after birth.

Choice D Reason: Possible Respiratory Distress Syndrome (RDS). This is a serious condition that requires immediate intervention and treatment, as RDS can lead to life-threatening complications such as pulmonary hemorrhage, pneumothorax, or bronchopulmonary dysplasia. RDS causes respiratory distress, nasal ﬂaring, retractions, grunting, and central cyanosis. It usually occurs within minutes to hours after birth.

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Correct Answer is A

Explanation

Choice A Reason: "Our baby's newborn rash is from this syndrome." This is because this statement by a parent indicates that additional teaching is required, as it shows a misunderstanding or confusion about FAS and its manifestations. FAS is a condition that occurs when a woman consumes alcohol during pregnancy, which can aﬀect the development and function of various organs and systems in the fetus and child. FAS can cause physical, behavioral, and cognitive problems such as facial abnormalities, growth retardation, learning difficulties, and atention deficits. FAS does not cause newborn rash, which is a common and benign condition that aﬀects many newborns regardless of maternal alcohol intake. Newborn rash is also known as erythema toxicum neonatorum or baby acne, which is characterized by small red bumps or pustules on the face, chest, or back that usually disappear within a few weeks.

Choice B Reason: "His face looks like it does due to this problem." This is a correct answer that indicates adequate understanding of FAS and its features. Facial abnormalities are one of the characteristic signs of FAS, which include small eye openings, thin upper lip, ﬂat nasal bridge, and smooth philtrum (the groove between the nose and upper lip).

Choice C Reason: "He can show signs of withdrawal from alcohol exposure like jiteriness, sweating, hyper reﬂexes, poor feeding and not sleeping well." This is a correct answer that indicates adequate understanding of FAS and its complications. Signs of withdrawal are possible eﬀects of FAS, which occur when the fetus or newborn is exposed to alcohol in utero or through breast milk, which can cause neurotoxicity and dependency. Signs of withdrawal can include jiteriness, sweating, hyper reﬂexes, poor feeding, and not sleeping well, as well as irritability, seizures, or tremors.

Choice D Reason: "He is at risk of having intellectual disabilities, so we will need to get extra services to support him." This is a correct answer that indicates adequate understanding of FAS and its implications. Intellectual disabilities are potential outcomes of FAS, which aﬀect the cognitive development and function of the child. Intellectual disabilities can cause problems with memory, Reasoning, language, and social skills. Extra services and support may be needed to help the child achieve their optimal potential and quality of life.

A. Moderate amounts of deep red lochia. B. Sweating while afebrile. C. Voiding 350 mL of blood-tinged urine. D. Heart rate of 115 beats/minute.

Correct Answer is D

Explanation

Choice A Reason: Moderate amounts of deep red lochia. This is not a finding that would warrant further investigation, but rather a normal finding for the early postpartum period. Lochia is the vaginal discharge that occurs after delivery, which consists of blood, mucus, and tissue from the uterus. Lochia is usually deep red in color and moderate in amount for the first few days after delivery.

Choice B Reason: Sweating while afebrile. This is not a finding that would warrant further investigation, but rather a common occurrence in the postpartum period. Sweating is a mechanism of thermoregulation that helps the body eliminate excess ﬂuid and electrolytes that were retained during pregnancy. Sweating does not necessarily indicate fever or infection.

Choice C Reason: Voiding 350 mL of blood-tinged urine. This is not a finding that would warrant further investigation, but rather an expected outcome for the postpartum period. Voiding large amounts of urine is normal in the postpartum period, as the body eliminates the excess ﬂuid that was accumulated during pregnancy. Blood-tinged urine may be due to trauma or irritation of the urinary tract during labor or delivery, which usually resolves within a few days.

Choice D Reason: Heart rate of 115 beats/minute. This is because a heart rate of 115 beats/minute is higher than the normal range for an adult, which is 60 to 100 beats/minute. A high heart rate may indicate postpartum hemorrhage, infection, pain, anxiety, or dehydration. The nurse should further assess the client for other signs and symptoms of these conditions and notify the physician if necessary.

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The nurse assesses a newborn at 36 weeks' gestation, and the following behaviors are noted: nasal ﬂaring, labored breathing, and excessive mucus. The nurse is most concerned about: Select one:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Parents have been told their child has fetal alcohol syndrome (FAS). Which statement by a parent indicates that additional teaching is required? Select one:

Correct Answer is A

Explanation

When the nurse is assessing a postpartum client approximately 6 hours after delivery, which finding would warrant further investigation? Select one:

Correct Answer is D

Explanation

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The nurse assesses a newborn at 36 weeks' gestation, and the following behaviors are noted: nasal ﬂaring, labored breathing, and excessive mucus. The nurse is most concerned about:
Select one: