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

Flaring of the nares

Shallow and irregular respirations

Respiratory rate of 50 breaths per minute

Abdominal breathing with synchronous chest movement

Answer and Explanation

The Correct Answer is A

A. Flaring of the nares:
Flaring of the nares is a clinical sign of respiratory distress in newborns. It indicates that the infant is working harder to breathe and is attempting to increase the size of the nostrils to get more air.

B. Shallow and irregular respirations:
Shallow and irregular respirations can be a sign of respiratory distress, but flaring of the nares is a more specific and immediate indication.

C. Respiratory rate of 50 breaths per minute:
While a respiratory rate of 50 breaths per minute might be within the normal range for a newborn, the overall clinical picture, including other signs of distress, should be considered.

D. Abdominal breathing with synchronous chest movement:
Abdominal breathing with synchronous chest movement is not a normal pattern for a newborn and could indicate respiratory distress.

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Correct Answer is B

Explanation

A. Bleeding tendencies:
Bleeding tendencies are not typically a priority immediately after birth unless there is a specific indication. Newborns are not at immediate risk for bleeding unless there are underlying conditions.

B. Heat loss:
Heat loss is a significant concern for newborns. Maintaining an adequate temperature is crucial to prevent hypothermia, which can lead to complications.

C. Hypoglycemia:
While monitoring blood glucose is important in the newborn, it may not be the most immediate concern within the first minutes after delivery. Stabilizing the newborn's temperature and initiating breathing are usually higher priorities.

D. Fluid balance:
Fluid balance is essential, but the initial focus is often on establishing respirations and maintaining temperature. Fluids may be administered as needed based on the clinical assessment.

A. Explain reasons consent for an infant autopsy is needed B. Determine if the mother desires a visit from her clergy C. Encourage the mother to hold and spend time with her baby D. Create a memory box of baby's footprints and photographs

Correct Answer is C

Explanation

Explain reasons consent for an infant autopsy is needed:
Autopsy might be necessary for understanding the cause of fetal demise, providing answers to the parents, and helping future pregnancies. However, it's not the most immediate or essential action in this scenario.

Determine if the mother desires a visit from her clergy:
Spiritual and emotional support is crucial during this distressing time. While clergy support is valuable, it's not the most urgent action needed immediately after delivery.

Encourage the mother to hold and spend time with her baby:
This is a crucial part of the grieving process and helps in acknowledging and creating memories with the baby. It's an essential step in providing emotional support to the mother.

Create a memory box of baby's footprints and photographs:
This is also a critical step in assisting the parents with the grieving process. It helps in cherishing the memories and creating keepsakes that may provide comfort in the future.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse receives a newborn within the first minutes after a vaginal delivery and intervenes to establish adequate respirations. What priority issue should the nurse address to ensure the newborn's survival?

Correct Answer is B

Explanation

The nurse is caring for a client whose fetus died in utero at 32-weeks gestation. After the fetus is delivered vaginally, the nurse implements routine fetal demise protocol and identification procedures Which action is most important for the nurse to take?

Correct Answer is C

Explanation

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