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 B

Explanation

Choice A rationale

Latanoprost eye drops are used to reduce intraocular pressure in glaucoma patients and are not relevant for a newborn exposed to Neisseria gonorrhoeae.

Choice B rationale

Erythromycin ointment is the correct medication to administer to a newborn exposed to Neisseria gonorrhoeae. It is used to prevent ophthalmia neonatorum, an eye infection caused by the bacteria. Administering erythromycin ointment is essential to protect the newborn's eyes from potential blindness or severe infection.

Choice C rationale

Tetracaine eye drops are a topical anesthetic used to numb the eyes during procedures and are not indicated for preventing neonatal eye infections caused by Neisseria gonorrhoeae.

Choice D rationale

Neomycin ointment is an antibiotic used for treating bacterial infections, but it is not the standard treatment for preventing ophthalmia neonatorum in newborns exposed to Neisseria gonorrhoeae. Erythromycin ointment is the recommended prophylactic treatment. .

A. Gravida 4: para 3. B. Fetal heart rate 136 to 142 beats/minute. C. Variable decelerations to 120 beats/minute lasting 20 seconds. D. 37-weeks, 1-day gestation by 10-week ultrasound. E. Pain rating of 5 on 0 to 10 pain scale with each contraction. F. Vaginal exam 4 cm dilated, 50% effaced, -3 station. G. Contractions every 3 to 4 minutes, moderate to palpation. H. A-blood type, received Rh(D) immune globulin.

Correct Answer is ["A","C","F"]

Explanation

Choice A rationale

Gravida 4 para 3 indicates a history of multiple pregnancies and deliveries, which can increase the risk of uterine atony, postpartum hemorrhage, and placental issues. This client’s obstetric history makes her high-risk due to potential complications associated with multiparity.

Choice B rationale

A fetal heart rate of 136 to 142 beats/minute is within the normal range for a fetus, indicating good fetal well-being. This data point does not place the client at increased risk.

Choice C rationale

Variable decelerations to 120 beats/minute lasting 20 seconds suggest umbilical cord compression, which can lead to fetal hypoxia if persistent and untreated. Variable decelerations are an indicator of potential fetal distress, making this a significant risk factor.

Choice D rationale

A gestation of 37-weeks, 1-day is considered term, and while there may be some risks associated with early-term delivery, this data point alone does not significantly increase risk in a low-risk pregnancy.

Choice E rationale

A pain rating of 5 on a 0 to 10 pain scale with each contraction is indicative of moderate pain, which is expected during labor. Pain severity alone does not increase the client's risk for complications.

Choice F rationale

A vaginal exam showing 4 cm dilation, 50% effacement, and -3 station indicates early labor. However, the -3 station suggests that the fetus is still high in the pelvis, which can be a concern if there is prolonged labor or failure to progress.

Choice G rationale

Contractions every 3 to 4 minutes, moderate to palpation, are consistent with active labor and are not indicative of an increased risk for complications in this context.

Choice H rationale

An A-blood type and receiving Rh(D) immune globulin address Rh incompatibility and prevention of hemolytic disease in the newborn. This data point does not place the client at increased risk.

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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

A client who is positive for Neisseria gonorrhoeae vaginally delivered a newborn.Which medication should the nurse administer to the newborn?

Correct Answer is B

Explanation

The nurse reviews the history and physical and nurses' notes to determine risk factors for this client.Which potential issue(s) place the client at risk? Select all that apply.

Correct Answer is ["A","C","F"]

Explanation

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