What symptom assessed in the newborn shortly after delivery should be reported?
Sternal or chest retractions
Cyanosis of the hands and feet
Mucus draining from the nose
Irregular heart rate
The Correct Answer is A
A. Sternal or chest retractions: Retractions indicate increased work of breathing and possible respiratory distress. This finding should be reported immediately, as it may signal airway obstruction, lung disease, or inadequate oxygenation that requires prompt intervention.
B. Cyanosis of the hands and feet: Peripheral cyanosis, or acrocyanosis, is common in newborns during the first 24 hours of life and generally resolves as circulation stabilizes. It does not typically indicate a pathological condition unless accompanied by central cyanosis.
C. Mucus draining from the nose: Mild nasal secretions are common in newborns due to residual amniotic fluid or normal respiratory clearing. This is a normal finding and does not require urgent reporting.
D. Irregular heart rate: Newborns often have transient variations in heart rate shortly after birth, especially during sleep or activity. Mild irregularities are usually benign and expected during the adaptation period.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Report the discrepancy to the pediatrician immediately: While significant or excessive weight loss should be reported, mild physiologic weight loss in the first few days of life is expected. Immediate reporting is not necessary if the loss is within the normal range of 5–10% of birth weight.
B. Decrease the interval between the infant's feedings: Newborns typically lose some weight in the first 3–5 days due to fluid shifts and limited intake. Increasing the frequency of feedings helps ensure adequate caloric intake and promotes gradual weight gain, supporting healthy growth and hydration.
C. Do nothing because this is a normal occurrence: Although some weight loss is normal, the nurse should take action to support feeding and monitor ongoing weight trends rather than ignoring the loss entirely.
D. Try feeding the infant a different type of formula: Changing formula is not indicated unless the infant has feeding intolerance or a medical reason. The initial intervention should focus on optimizing feeding frequency and technique rather than switching formula.
Correct Answer is D
Explanation
A. Encourage the client to perform Kegel exercises: Kegel exercises strengthen pelvic floor muscles but do not correct uterine displacement or address a boggy fundus. They are not an immediate intervention for preventing postpartum hemorrhage.
B. Ask the client to rate her pain: While assessing pain is important, it does not address the primary concern of a boggy, displaced fundus, which increases the risk of uterine atony and hemorrhage.
C. Encourage the client to move to the left lateral position: Lateral positioning may improve comfort or circulation but does not correct a full bladder or a displaced, boggy uterus.
D. Assist the client to the bathroom to void: A fundus displaced to the right often indicates bladder distention. Encouraging the client to void can relieve pressure on the uterus, allowing it to contract effectively and reduce the risk of postpartum hemorrhage.
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