The nurse is assessing a newborn who is 12 hours old. Which symptoms would indicate the newborn is experiencing respiratory distress?(Select all that apply)
grunting
increased appetite
inspiratory stridor
retractions
nasal flaring
Correct Answer : A,C,D,E
A. Grunting is an expiratory sound produced when a newborn partially closes the glottis during exhalation. This helps maintain positive airway pressure, keeps alveoli open, and improves oxygenation. Persistent grunting indicates the newborn is working hard to breathe and is a classic early sign of respiratory distress.
B. Increased appetite is not a symptom of respiratory distress. In fact, newborns experiencing distress often have difficulty feeding or show poor coordination of sucking and swallowing because breathing requires increased effort. Feeding difficulties, rather than increased appetite, may accompany respiratory compromise.
C. Stridor is a high-pitched sound heard during inspiration, typically caused by upper airway obstruction. It may result from conditions such as laryngomalacia, vocal cord paralysis, or airway edema. Stridor is a red flag for respiratory compromise and requires prompt assessment and monitoring.
D. Retractions occur when a newborn uses accessory muscles to breathe, pulling the skin inward around the sternum, ribs, or clavicles. This indicates increased work of breathing and reduced lung compliance. Retractions are a reliable physical sign of significant respiratory distress.
E. Nasal flaring occurs when the nostrils widen during inspiration to increase airflow. It is one of the earliest visible signs of respiratory distress and signals that the newborn is compensating for hypoxia or increased airway resistance.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Hydralazine is an antihypertensive used to manage severe hypertension in preeclampsia. While controlling blood pressure is essential in preeclampsia, hydralazine does not reverse the toxic effects of magnesium. Administering hydralazine in this context would not address the immediate life-threatening neuromuscular or respiratory depression.
B. Methylergonovine is a uterotonic agent used to treat postpartum hemorrhage by stimulating uterine contractions. It has no effect on magnesium toxicity and is unrelated to seizure prophylaxis or respiratory function. Administering this drug would not correct the client’s critical condition.
C. Naloxone is an opioid antagonist used to reverse opioid-induced respiratory depression. Magnesium sulfate toxicity is not opioid-related, so Narcan would not improve respiratory rate, restore reflexes, or address neuromuscular blockade caused by magnesium.
D. Calcium gluconate is the specific antidote for magnesium sulfate toxicity. It works by antagonizing the effects of magnesium at the neuromuscular junction, restoring deep tendon reflexes, and improving respiratory muscle function. Administration is intravenous, slow, and under close monitoring. Simultaneously, the magnesium infusion should be stopped immediately to prevent further accumulation. After stabilization, the nurse should monitor vital signs, urine output, reflexes, and serum magnesium levels to ensure safe recovery.
Correct Answer is B
Explanation
A. Hypoglycemia in newborns is generally caused by maternal diabetes, preterm birth, intrauterine growth restriction, or perinatal stress. It occurs because the newborn produces excess insulin or has limited glycogen stores. Rh sensitization does not affect glucose metabolism, so neonatal hypoglycemia is unrelated to maternal Rh status.
B. If an Rh-negative mother becomes sensitized after delivering an Rh-positive infant without receiving Rho(D) immune globulin, she can form anti-Rh antibodies. In a future pregnancy with an Rh-positive fetus, these antibodies can cross the placenta and destroy fetal red blood cells, causing hemolytic disease of the newborn (HDN). Severe HDN may lead to fetal anemia, hydrops fetalis, or miscarriage/stillbirth if left untreated.
C. Macrosomia, defined as birth weight >4,000–4,500 g, is typically associated with maternal diabetes, maternal obesity, or genetic predisposition. Rh incompatibility does not influence fetal growth or increase the risk of macrosomia, so it is not a concern in sensitized mothers.
D. Placenta previa occurs when the placenta partially or completely covers the cervical os, which can cause bleeding during pregnancy. Its risk factors include previous cesarean delivery, uterine surgery, multiple gestations, or advanced maternal age, but Rh sensitization has no effect on placental location, so it is unrelated.
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