The nurse is caring for a newborn one hour after delivery.
Which of the following assessment findings does the nurse identify as signs of respiratory distress? (Select all that apply)
Flexion of arms.
Caput succedaneum.
Heart rate 158 bpm.
Respiratory rate 66/min.
Acrocyanosis.
Subcostal retractions.
Nasal flaring.
Grunting.
Correct Answer : D,F,G,H
Choice A rationale
Flexion of arms is a normal finding in newborns and does not indicate respiratory distress.
Choice B rationale
Caput succedaneum is a common condition where the scalp swells due to pressure during delivery. It does not indicate respiratory distress.
Choice C rationale
A heart rate of 158 bpm is within the normal range for newborns and does not indicate respiratory distress.
Choice D rationale
A respiratory rate of 66/min is above the normal range (30-60 breaths per minute) and indicates respiratory distress.
Choice E rationale
Acrocyanosis is common in newborns and does not indicate respiratory distress.
Choice F rationale
Subcostal retractions indicate increased work of breathing and are a sign of respiratory distress.
Choice G rationale
Nasal flaring is a sign of respiratory distress as it indicates increased effort to breathe.
Choice H rationale
Grunting is a sign of respiratory distress as it indicates difficulty in maintaining lung expansion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Faint red marks on the plantar surface are more common in preterm infants and are not typically seen in post-term infants.
Choice B rationale
Copious vernix is usually seen in preterm infants. Post-term infants often have little to no vernix.
Choice C rationale
Dry, cracked skin is a common finding in post-term infants due to prolonged exposure to the amniotic fluid.
Choice D rationale
Scant scalp hair is more common in preterm infants. Post-term infants usually have more developed hair.
Correct Answer is D
Explanation
Choice A rationale
Microcephaly is not typically associated with an increased risk of unconjugated bilirubin and jaundice.
Choice B rationale
Polydactyly is a congenital condition involving extra fingers or toes and is not associated with an increased risk of unconjugated bilirubin and jaundice.
Choice C rationale
Caput succedaneum is a condition involving swelling of the scalp in a newborn and is not typically associated with an increased risk of unconjugated bilirubin and jaundice.
Choice D rationale
Cephalohematoma is a collection of blood between a baby’s scalp and the skull bone. It is associated with an increased risk of unconjugated bilirubin and jaundice due to the breakdown of red blood cells in the hematoma. .
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