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

Respiratory rate of 50 breaths per minute.

Shallow and irregular respirations.

Flaring of the nares.

Abdominal breathing with synchronous chest movement.

Answer and Explanation

The Correct Answer is C

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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Correct Answer is D

Explanation

Assessing vital signs is important but not the most immediate action for heavy postpartum bleeding. It provides information about the client's current status but does not address the bleeding directly.

Choice B rationale

Increasing the IV infusion rate can help manage blood loss by maintaining blood volume, but it is not the first action to take when managing postpartum hemorrhage.

Choice C rationale

Notifying the healthcare provider is important but secondary to addressing the immediate cause of the bleeding. The provider will need information about the client's status and the actions taken to manage the situation.

Choice D rationale

Massaging the fundus is the most immediate and effective action to reduce postpartum hemorrhage. It stimulates uterine contractions, which helps to clamp down on the blood vessels and stop the bleeding.

A. Increase IV fluids. B. Obtain blood pressure. C. Stop infusion of magnesium. D. Administer oxygen. E. Obtain serum magnesium level. F. Prepare for a cesarean delivery. G. Administer calcium gluconate. H. Prepare to prevent respiratory or cardiac arrest.

Correct Answer is ["A","C","D","E","G"]

Explanation

Choice A rationale

Increasing IV fluids is a critical intervention to maintain maternal hemodynamic stability and prevent complications related to fluid imbalance. It helps support blood pressure and overall fluid status during labor and delivery.

Choice B rationale

While obtaining blood pressure is important for monitoring maternal status, it is not an immediate intervention compared to others listed. Blood pressure monitoring is part of routine assessment but not an emergency action.

Choice C rationale

Stopping the infusion of magnesium is essential if there are signs of magnesium toxicity or adverse effects. Magnesium can impact respiratory and cardiac function, so stopping the infusion is a priority.

Choice D rationale

Administering oxygen is an immediate intervention to ensure adequate oxygenation for both the mother and the fetus. It is crucial during labor and delivery to prevent hypoxia and related complications.

Choice E rationale

Obtaining serum magnesium level is necessary to assess for magnesium toxicity and guide further interventions. It provides important information on the mother's magnesium status and helps in making clinical decisions.

Choice F rationale

Preparing for a cesarean delivery is not an immediate intervention unless there are specific indications for surgical delivery. It should be based on clinical findings and maternal-fetal status.

Choice G rationale

Administering calcium gluconate is the antidote for magnesium toxicity and is an immediate intervention if signs of toxicity are present. It helps counteract the effects of excessive magnesium.

Choice H rationale

Preparing to prevent respiratory or cardiac arrest is a critical intervention in severe cases of magnesium toxicity, but it should be part of a broader emergency management plan rather than an immediate action. .

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

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Naxlex Comprehensive Predictor Exams

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Explanation

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