Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
The nurse is assessing a newborn who is 12 hours old. Which symptoms would indicate the newborn is experiencing respiratory distress?(Select all that apply)
A. grunting
Grunting is an expiratory sound produced when a newborn partially closes the glottis during exhalation. This helps maintain positive airway pressure, keeps alveoli open, and improves oxygenation. Persistent grunting indicates the newborn is working hard to breathe and is a classic early sign of respiratory distress.
B. increased appetite
Increased appetite is not a symptom of respiratory distress. In fact, newborns experiencing distress often have difficulty feeding or show poor coordination of sucking and swallowing because breathing requires increased effort. Feeding difficulties, rather than increased appetite, may accompany respiratory compromise.
C. inspiratory stridor
Stridor is a high-pitched sound heard during inspiration, typically caused by upper airway obstruction. It may result from conditions such as laryngomalacia, vocal cord paralysis, or airway edema. Stridor is a red flag for respiratory compromise and requires prompt assessment and monitoring.
D. retractions
Retractions occur when a newborn uses accessory muscles to breathe, pulling the skin inward around the sternum, ribs, or clavicles. This indicates increased work of breathing and reduced lung compliance. Retractions are a reliable physical sign of significant respiratory distress.
E. nasal flaring
Nasal flaring occurs when the nostrils widen during inspiration to increase airflow. It is one of the earliest visible signs of respiratory distress and signals that the newborn is compensating for hypoxia or increased airway resistance.
This question is an excerpt from Nurse Dive's nursing test bank - Ati Demsn 650 Pediatrics Proctored Exam. Take the full exam now
Full Explanation
A. Grunting is an expiratory sound produced when a newborn partially closes the glottis during exhalation. This helps maintain positive airway pressure, keeps alveoli open, and improves oxygenation. Persistent grunting indicates the newborn is working hard to breathe and is a classic early sign of respiratory distress.
B. Increased appetite is not a symptom of respiratory distress. In fact, newborns experiencing distress often have difficulty feeding or show poor coordination of sucking and swallowing because breathing requires increased effort. Feeding difficulties, rather than increased appetite, may accompany respiratory compromise.
C. Stridor is a high-pitched sound heard during inspiration, typically caused by upper airway obstruction. It may result from conditions such as laryngomalacia, vocal cord paralysis, or airway edema. Stridor is a red flag for respiratory compromise and requires prompt assessment and monitoring.
D. Retractions occur when a newborn uses accessory muscles to breathe, pulling the skin inward around the sternum, ribs, or clavicles. This indicates increased work of breathing and reduced lung compliance. Retractions are a reliable physical sign of significant respiratory distress.
E. Nasal flaring occurs when the nostrils widen during inspiration to increase airflow. It is one of the earliest visible signs of respiratory distress and signals that the newborn is compensating for hypoxia or increased airway resistance.
Similar Questions
A pregnant client completes the 1-hour glucose tolerance test (GTT) at 26 weeks' gestation. The nurse explains that if the blood glucose result is above ____ to ____mg/dL. It is considered a positive screening and the client will need a 3-hour oral glucose tolerance test.
Full Explanation
The 1-hour GTT is a screening test for gestational diabetes mellitus (GDM) performed between 24–28 weeks of gestation. The client drinks a 50-gram glucose solution, and blood glucose is measured 1 hour later.
- A result ≤130–140 mg/dL is considered normal, indicating the client is unlikely to have GDM.
- A result above 130–140 mg/dL is considered positive, prompting a 3-hour, 100-gram OGTT to confirm the diagnosis.
A 12-year-old child with sickle cell disease is admitted with a vaso-occlusive crisis. The child rates pain as 10/10 but refuses IV opioids due to fear of needles. Which intervention should the nurse implement FIRST?
A. Document the refusal and delay analgesia.
Delaying pain management is not appropriate in a child experiencing a vaso-occlusive crisis. Pain relief is a priority nursing intervention, and documenting refusal without offering alternatives does not address the child’s suffering.
B. Explain that pain medication is mandatory.
Forcing medication or implying it is mandatory can increase the child’s fear and anxiety, potentially worsening pain and reducing cooperation. It is not a therapeutic approach and does not respect the child’s autonomy.
C. Ask the child to wait until the pain becomes severe.
Waiting is unsafe and unethical. A pain score of 10/10 indicates severe pain that requires prompt management. Delaying treatment can increase the risk of pain-related complications, including stress-induced vaso-occlusion or prolonged crisis.
D. Offer nonpharmacologic pain.
Since the child refuses IV opioids due to fear of needles, the nurse should first implement alternative strategies while respecting the child’s autonomy. Nonpharmacologic interventions for sickle cell pain include distraction techniques such as videos, games, or music, guided imagery or relaxation exercises, heat application to affected joints, and deep breathing exercises. These approaches can reduce anxiety and pain perception and can be used immediately while exploring other analgesic options, such as oral opioids, patient-controlled analgesia, or topical analgesics.
Full Explanation
A. Delaying pain management is not appropriate in a child experiencing a vaso-occlusive crisis. Pain relief is a priority nursing intervention, and documenting refusal without offering alternatives does not address the child’s suffering.
B. Forcing medication or implying it is mandatory can increase the child’s fear and anxiety, potentially worsening pain and reducing cooperation. It is not a therapeutic approach and does not respect the child’s autonomy.
C. Waiting is unsafe and unethical. A pain score of 10/10 indicates severe pain that requires prompt management. Delaying treatment can increase the risk of pain-related complications, including stress-induced vaso-occlusion or prolonged crisis.
D. Since the child refuses IV opioids due to fear of needles, the nurse should first implement alternative strategies while respecting the child’s autonomy. Nonpharmacologic interventions for sickle cell pain include distraction techniques such as videos, games, or music, guided imagery or relaxation exercises, heat application to affected joints, and deep breathing exercises. These approaches can reduce anxiety and pain perception and can be used immediately while exploring other analgesic options, such as oral opioids, patient-controlled analgesia, or topical analgesics.
The patient has an order for a single dose of ceftriaxone 400 mg IM. The final concentration is 500 mg/1.2 ml. How many milliliters will you administer? (Round to the nearest hundredth.)
Full Explanation
Ordered dose = 400 mg
Available = 500 mg in 1.2 mL
Step 1: Use the formula
Volume to administer = (Ordered dose ÷ Available dose) × Volume available
Step 2: Substitute the values
Volume = (400 ÷ 500) × 1.2
Step 3: Calculate
Volume = 0.8 × 1.2 = 0.96 mL