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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 B

Explanation

Choice A rationale

Erythema toxicum is a common, benign rash in newborns but does not cause swelling that crosses suture lines.

Choice B rationale

A caput succedaneum is swelling of the scalp that crosses suture lines and is caused by prolonged pressure on the head during delivery.

Choice C rationale

Mongolian spots are benign, flat, congenital birthmarks with wavy borders and irregular shapes, typically found on the lower back and buttocks, not the head.

Choice D rationale

A cephalhematoma is a collection of blood between the skull bone and its periosteum that does not cross suture lines. .

A. Milia B. Barrel-shaped chest C. Respiratory rate 66/min D. Acrocyanosis present E. Polydactyly

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"B"}}

Explanation

A. Milia: Expected (normal) finding.

B. Barrel-shaped chest: Expected (normal) finding.

C. Respiratory rate 66/min: Abnormal finding.

D. Acrocyanosis present: Expected (normal) finding.

E. Polydactyly: Abnormal finding.

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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

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is B

Explanation

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Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"B"}}

Explanation

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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)