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 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. .
Correct Answer is A
Explanation
Choice A rationale
The Babinski reflex is elicited by stroking the outer edge of the sole of the newborn’s foot, moving up toward the toes. This causes the big toe to move upward and the other toes to fan out.
Choice B rationale
Turning the newborn’s head quickly to one side is used to elicit the tonic neck reflex, not the Babinski reflex.
Choice C rationale
Holding the newborn vertically and allowing one foot to touch the table surface is used to elicit the stepping reflex, not the Babinski reflex.
Choice D rationale
Clapping near the crib and making a loud noise is used to elicit the startle (Moro) reflex, not the Babinski reflex.
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