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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.

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Correct Answer is ["A","B","C","E"]

Explanation

Choice A rationale

Sucking on their fingers is an early hunger cue in infants. It indicates that the baby is ready to feed.

Choice B rationale

Smacking their lips is another early hunger cue. It shows that the baby is thinking about feeding.

Choice C rationale

Extending their tongue is also an early hunger cue. It indicates that the baby is ready to latch onto the breast or bottle.

Choice D rationale

Crying is a late hunger cue. It is better to feed the baby before they start crying to make feeding easier.

Choice E rationale

Rooting is an early hunger cue. It involves the baby turning their head towards the breast or bottle, indicating they are ready to feed. .

A. Hepatitis B vaccine only, administered within 1 hour of birth. B. Hepatitis B vaccine and Hepatitis B immunoglobulin administered within 12 hours of delivery. C. Hepatitis B immunoglobulin (HBIG) only, administered within 12 hours of birth. D. Hepatitis B immunoglobulin (HBIG) within 12 hours, followed by hepatitis B vaccine monthly for 12 months.

Correct Answer is B

Explanation

Choice A rationale

Administering only the Hepatitis B vaccine within 1 hour of birth is not sufficient for a newborn born to a Hepatitis B positive mother. The newborn also needs Hepatitis B immunoglobulin (HBIG) to provide immediate passive immunity.

Choice B rationale

Administering both the Hepatitis B vaccine and Hepatitis B immunoglobulin (HBIG) within 12 hours of delivery is the recommended practice for newborns born to Hepatitis B positive mothers. This provides both active and passive immunity.

Choice C rationale

Administering only Hepatitis B immunoglobulin (HBIG) within 12 hours of birth is not sufficient. The newborn also needs the Hepatitis B vaccine to develop long-term immunity.

Choice D rationale

Administering Hepatitis B immunoglobulin (HBIG) within 12 hours, followed by monthly Hepatitis B vaccines for 12 months, is not the standard practice. The newborn should receive the Hepatitis B vaccine series according to the recommended schedule. .

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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

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Explanation

Correct Answer is B

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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)