Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
Which finding would alert the nurse to suspect that a newborn is experiencing respiratory distress?
A. asymmetrical chest movement
Asymmetrical chest movement is a sign of respiratory distress in the newborn, as it indicates unequal lung expansion or airway obstruction. A respiratory rate of 50 breaths/minute (choice B) is normal for a newborn, as is acrocyanosis (choice C), which is a bluish discoloration of the hands and feet due to immature peripheral circulation. Short periods of apnea (less than 15 seconds) (choice D) are also common and benign in newborns unless they are associated with bradycardia or cyanosis.
B. respiratory rate of 50 breaths/minute
This is not correct because a respiratory rate of 50 breaths/minute is within the normal range for a newborn.
C. acrocyanosis
This is not correct because acrocyanosis is a normal finding in newborns and does not indicate respiratory distress.
D. short periods of apnea (less than 15 seconds)
This is not correct because short periods of apnea (less than 15 seconds) are normal in newborns and do not indicate respiratory distress.
This question is an excerpt from Nurse Dive's nursing test bank - Postpartum AMD Newborn Care Proctored Exam. Take the full exam now
Full Explanation
Asymmetrical chest movement is a sign of respiratory distress in the newborn, as it indicates unequal lung expansion or airway obstruction. A respiratory rate of 50 breaths/minute (choice B) is normal for a newborn, as is acrocyanosis (choice C), which is a bluish discoloration of the hands and feet due to immature peripheral circulation. Short periods of apnea (less than 15 seconds) (choice D) are also common and benign in newborns unless they are associated with bradycardia or cyanosis.
Choice B is not correct because a respiratory rate of 50 breaths/minute is within the normal range for a newborn.
Choice C is not correct because acrocyanosis is a normal finding in newborns and does not indicate respiratory distress.
Choice D is not correct because short periods of apnea (less than 15 seconds) are normal in newborns and do not indicate respiratory distress.
Similar Questions
The nurse is caring for a new mother and newborn in a rooming-in unit and watches the mother put the infant in the bed, lying on her side, propped up with a pillow. The nurse should point out that this position can increase the risk of which situation?
A. Gastroesophageal reflux
This is incorrect because gastroesophageal reflux (GER) is a common condition in infants that causes them to spit up frequently after feeding. GER does not increase the risk of SIDS and can be managed by feeding smaller amounts, burping the infant often, and keeping them upright for a while after feeding.
B. Sudden infant death syndrome
Sudden infant death syndrome (SIDS) is the sudden and unexplained death of an infant under one year of age. SIDS is more likely to occur when infants sleep on their stomachs or sides, or when they are propped up with pillows or other soft bedding. These positions can interfere with the infant's breathing and increase the risk of suffocation or overheating.
C. Apnea episodes
This is incorrect because apnea episodes are brief pauses in breathing that occur normally in infants, especially during sleep. Apnea episodes do not increase the risk of SIDS and usually resolve by six months of age.
D. Sleeping for short intervals
This is incorrect because sleeping for short intervals is normal for newborns, who need to feed frequently during the day and night. Sleeping for short intervals does not increase the risk of SIDS and will gradually change as the infant grows older.
Full Explanation
Sudden infant death syndrome (SIDS) is the sudden and unexplained death of an infant under one year of age. SIDS is more likely to occur when infants sleep on their stomachs or sides, or when they are propped up with pillows or other soft bedding. These positions can interfere with the infant's breathing and increase the risk of suffocation or overheating .
Choice A is incorrect because gastroesophageal reflux (GER) is a common condition in infants that causes them to spit up frequently after feeding. GER does not increase the risk of SIDS and can be managed by feeding smaller amounts, burping the infant often, and keeping them upright for a while after feeding.
Choice C is incorrect because apnea episodes are brief pauses in breathing that occur normally in infants, especially during sleep. Apnea episodes do not increase the risk of SIDS and usually resolve by six months of age.
Choice D is incorrect because sleeping for short intervals is normal for newborns, who need to feed frequently during the day and night. Sleeping for short intervals does not increase the risk of SIDS and will gradually change as the infant grows older.
Within three days of birth, a newborn has developed a yellowish tinge that extends from the face to mid-chest is lethargic, and has to be awakened to feed. Which condition does the nurse suspect this infant is manifesting?
A. Physiologic jaundice
Physiologic jaundice usually appears between the second and fourth day after birth and resolves by the second week. It is caused by the immature liver's inability to process bilirubin efficiently.
B. Pathologic jaundice
This type of jaundice occurs within the first 24 hours of birth and is caused by an underlying health condition, such as blood type incompatibility, infection, or liver problems. It can lead to serious complications, such as brain damage, if not treated promptly.
C. Breast milk jaundice
This is not correct because breast milk jaundice is a rare condition that affects some breastfed babies. It usually appears after the first week of life and lasts up to a month or longer. It is caused by a substance in breast milk that interferes with the liver's ability to eliminate bilirubin.
Full Explanation
Physiologic jaundice usually appears between the second and fourth day after birth and resolves by the second week. It is caused by the immature liver's inability to process bilirubin efficiently.
A nurse is collecting data from a postpartum client and finds a large amount of lochia rubra with several clots on the client's perineal pad. Which of the following actions should the nurse take first?
A. Request the provider perform a vaginal examination.
This is incorrect because requesting the provider perform a vaginal examination is not the first action the nurse should take. A vaginal examination may be necessary if the fundal massage does not reduce the bleeding or if there is a suspicion of lacerations or hematoma, but it is not a priority intervention.
B. Check the client's fundus.
Check the client's fundus. Lochia rubra is the normal vaginal bleeding and discharge that occurs after childbirth. It consists of blood, mucus, and tissue from the placenta and the uterus lining. It is usually bright red and may have some clots, but these clots should not be big or difficult to pass. If the client has a large amount of lochia rubra with several clots, it may indicate that the uterus is not contracting well and needs to be massaged to expel any retained tissue or blood. Checking the client's fundus is the first action the nurse should take to assess the uterine tone and location.
C. Measure the client's vital signs.
This is incorrect because measuring the client's vital signs is not the first action the nurse should take. Vital signs can help monitor the client's hemodynamic status and identify signs of shock, such as tachycardia, hypotension, and pallor, but they are not as important as checking the fundus in this situation.
D. Feel for a full bladder.
This is incorrect because feeling for a full bladder is not the first action the nurse should take. A full bladder can displace the uterus and interfere with its contraction, leading to increased bleeding. However, it is not as likely as uterine atony to cause a large amount of lochia rubra with several clots.
Full Explanation
Check the client's fundus. Lochia rubra is the normal vaginal bleeding and discharge that occurs after childbirth. It consists of blood, mucus, and tissue from the placenta and the uterus lining. It is usually bright red and may have some clots, but these clots should not be big or difficult to pass. If the client has a large amount of lochia rubra with several clots, it may indicate that the uterus is not contracting well and needs to be massaged to expel any retained tissue or blood. Checking the client's fundus is the first action the nurse should take to assess the uterine tone and location.
Choice A is incorrect because requesting the provider perform a vaginal examination is not the first action the nurse should take. A vaginal examination may be necessary if the fundal massage does not reduce the bleeding or if there is a suspicion of lacerations or hematoma, but it is not a priority intervention.
Choice C is incorrect because measuring the client's vital signs is not the first action the nurse should take. Vital signs can help monitor the client's hemodynamic status and identify signs of shock, such as tachycardia, hypotension, and pallor, but they are not as important as checking the fundus in this situation.
Choice D is incorrect because feeling for a full bladder is not the first action the nurse should take. A full bladder can displace the uterus and interfere with its contraction, leading to increased bleeding. However, it is not as likely as uterine atony to cause a large amount of lochia rubra with several clots.