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 C

Explanation

Choice A rationale

While bulb syringe use is important for clearing the newborn's airways, it is not the immediate priority during the fourth stage of labor. This information can be provided later during routine newborn care education.

Choice B rationale

Newborn screening tests are important for identifying potential health issues, but the fourth stage of labor is focused on stabilizing the mother and infant and initiating breastfeeding. Screening information can be shared during the postpartum period.

Choice C rationale

Techniques to breastfeed are critical information to provide during the fourth stage of labor as it helps establish successful breastfeeding early on. This support can enhance maternal-infant bonding and promote breastfeeding success.

Choice D rationale

Circumcision care is relevant for parents who choose to circumcise their infant, but it is not the immediate priority during the fourth stage of labor. This information can be provided during subsequent postpartum visits.

A. Obtain a heel stick blood glucose level. B. Swaddle the infant in a warm blanket. C. Place a pulse oximeter on the heel. D. Document the findings in the record.

Correct Answer is A

Explanation

Choice A rationale

The symptoms of jitteriness, hypotonia, weak cry, and low temperature can indicate hypoglycemia in a newborn. Obtaining a heel stick blood glucose level is crucial to confirm the diagnosis and provide appropriate treatment.

Choice B rationale

While keeping the infant warm is important, it does not address the underlying issue of potential hypoglycemia, which needs to be identified and treated promptly.

Choice C rationale

Placing a pulse oximeter on the heel assesses oxygen saturation, which is not directly related to the symptoms described. The primary concern here is glucose level, not oxygen saturation.

Choice D rationale

Documenting the findings is important but does not provide immediate intervention for potential hypoglycemia, which requires urgent glucose level assessment and treatment if necessary. .

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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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Correct Answer is C

Explanation

Correct Answer is A

Explanation

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