The nurse is caring for a newborn who is 18 inches long, weighs 4 pounds, 14 ounces (2.2 kg), has a head circumference of 13 inches (33 cm), and a chest circumference of 10 inches (25.4 cm). Based on these physical findings, assessment for which condition has the highest priority?

A. Hypoglycemia.

Polycythemia.

Hyperthermia.

Hyperbilirubinemia.

None

Answer and Explanation

The Correct Answer is A

Hypoglycemia is a common concern for newborns with low birth weight. Their glucose reserves are limited, and they have a higher metabolic rate, making them prone to low blood sugar levels.

Choice B rationale

Polycythemia, an increased red blood cell count, is not typically a primary concern based on the measurements given. It is more commonly associated with conditions like delayed cord clamping or maternal diabetes.

Choice C rationale

Hyperthermia is not a primary concern based on the provided measurements. Thermoregulation issues might arise, but initial focus should be on managing glucose levels.

Choice D rationale

Hyperbilirubinemia, or jaundice, can occur in newborns but is not the immediate priority based on the given physical findings. Monitoring and managing blood sugar levels is more critical in the initial hours after birth.

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Correct Answer is D

Explanation

Choice D rationale

Low back pain with pelvic cramping can indicate complications such as premature labor or an infection after an amniocentesis.

Choice A rationale

Increased fetal movement is not typically a sign of complications following amniocentesis and may be a normal finding.

Choice B rationale

Headache and blurred vision are concerning symptoms but are not directly related to amniocentesis complications.

Choice C rationale

Epigastric pain can be a sign of other issues, such as preeclampsia, but not specifically related to amniocentesis complications. .

A. Respiratory rate of 50 breaths per minute. B. Shallow and irregular respirations. C. Flaring of the nares. D. Abdominal breathing with synchronous chest movement.

Correct Answer is C

Explanation

Choice A rationale

A respiratory rate of 50 breaths per minute is within the normal range for a newborn and does not indicate respiratory distress. Newborns typically have a higher respiratory rate than adults, and this is considered normal.

Choice B rationale

Shallow and irregular respirations can occur in healthy newborns and do not necessarily indicate respiratory distress. It is important to monitor for additional signs of distress before making a definitive assessment.

Choice C rationale

Flaring of the nares is a sign of respiratory distress in newborns as it indicates increased effort to breathe. This symptom is associated with conditions such as respiratory distress syndrome and requires prompt medical evaluation and intervention.

Choice D rationale

Abdominal breathing with synchronous chest movement is normal for newborns as their diaphragm is the primary muscle for respiration. This type of breathing pattern does not indicate respiratory distress and is expected in healthy newborns.

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The nurse is caring for a newborn who is 18 inches long, weighs 4 pounds, 14 ounces (2.2 kg), has a head circumference of 13 inches (33 cm), and a chest circumference of 10 inches (25.4 cm). Based on these physical findings, assessment for which condition has the highest priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Following an amniocentesis, a client verbalizes several concerns.Which reported finding indicates to the nurse that the client is experiencing a complication from the amniocentesis?

Correct Answer is D

Explanation

The nurse is performing a newborn assessment.Which symptom, if present in a newborn, would indicate respiratory distress?

Correct Answer is C

Explanation

When reading the obstetrical history of a client who is currently at 36 weeks gestation, the nurse notes that she has had one full-term infant, one premature infant born at 32 weeks gestation that survived, and one miscarriage.Which is this client's gravidity?

The current vital signs for a primipara who delivered vaginally during the previous shift are: temperature 100.4°F (38°C), heart rate 58 beats/minute, respiratory rate 16 breaths/minute, and blood pressure 130/74 mm Hg. Which action should the nurse implement?

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The nurse reviews the assessment findings along with the healthcare provider's prescriptions.Which immediate intervention(s) would the nurse initiate? Select all that apply.

During a routine prenatal health assessment for a client in her third trimester, the client reports that she had fluid leakage on her way to the appointment.Which technique should the nurse implement to evaluate the leakage?

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