Try Naxlex NCLEX-RN (Free-Trial)

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.

Answer and Explanation

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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A rationale

Shivering is not a primary concern for newborns as they have limited ability to shiver. Instead, they rely on non-shivering thermogenesis to maintain body temperature.

Choice B rationale

Cold stress is a significant concern for newborns as it can lead to hypothermia, increased oxygen consumption, and metabolic acidosis. Placing a newborn under a radiant heat warmer helps maintain their body temperature and prevent cold stress.

Choice C rationale

Brown fat production is a natural process in newborns that helps generate heat. However, the primary purpose of using a radiant heat warmer is to prevent cold stress, not to stimulate brown fat production.

Choice D rationale

Basal metabolic rate reduction is not the primary concern. The focus is on preventing cold stress and maintaining the newborn’s body temperature.

A. Ask another nurse to verify the heart rate as this is an abnormal finding. B. Call the provider and request they come to the hospital immediately for this abnormal finding to further assess the neonate. C. Prepare the newborn for transport to the NICU for further cardiac observation. D. Document the expected finding.

Correct Answer is D

Explanation

Choice A rationale

An apical pulse rate of 124 bpm is within the normal range for a neonate (110-160 bpm). There is no need to ask another nurse to verify the heart rate as it is not an abnormal finding.

Choice B rationale

Calling the provider for an apical pulse rate of 124 bpm is unnecessary as it is within the normal range for a neonate. This action would be appropriate if the heart rate were significantly outside the normal range.

Choice C rationale

Preparing the newborn for transport to the NICU for an apical pulse rate of 124 bpm is not warranted. The heart rate is within the normal range, and there is no indication for further cardiac observation.

Choice D rationale

Documenting the expected finding is the appropriate action. An apical pulse rate of 124 bpm is within the normal range for a neonate, and no further action is needed.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse places a newborn under a radiant heat warmer after birth.The purpose of this action is to prevent which of the following in the newborn?

Correct Answer is B

Explanation

A nursery nurse is admitting a neonate and is performing the neonatal assessment.The apical pulse is auscultated with a rate of 124 bpm, after one full minute of listening.What is the next appropriate action should the nurse take?

Correct Answer is D

Explanation

A nurse is assessing a newborn and evaluating for developmental dysplasia of the hip (DDH). What assessment finding would indicate DDH?

A nurse is assessing a newborn 1 hour after birth.Which of the following respiratory rates is within the expected reference range for a newborn?

The nurse is preparing to teach the postpartum mom about newborn feeding cues.Which of the following behaviors of the infant would be considered early hunger cues? Select all that apply.

A nurse is caring for a newborn who was born at 39 weeks gestation and weighs 3350 g. Based on the weight and gestational age, what is the most appropriate way to document the findings?

A nurse is preparing to administer 0.5% Erythromycin ophthalmic ointment to a newborn.Which route and dose should the nurse apply?

A nurse is caring for a newborn delivered by vaginal birth after 3 hours of pushing.The newborn’s mother asks about the swollen area on her son’s head.After palpation and identification that the swelling does cross the suture line, which of the following is an appropriate response by the nurse?

A nurse in the newborn nursery is caring for a group of newborns.Which of the following newborns requires immediate intervention?

Which of the following statements accurately describes a characteristic of the newborn immune system?

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)