Nokea
The nurse assess that a newborn is in respiratory distress when the infant exhibits:
- A. Apnea, grunting, wheezing, and crackles
- B. Wheezing, cyanosis, hiccups, and crackles
- C. Cyanosis, retraction, wheezing, and hiccups
- D. Tachypnea, retraction, grunting, and cyanosis
Correct Answer: D
Rationale: These are classic signs of respiratory distress.
You may also like to solve these questions
On admission to the nursery, a newborn is observed to be experiencing cold stress. The basis for the nursing intervention at this time would be to minimize:
- A. Shivering
- B. Hyperglycemia
- C. Oxygen consumption
- D. Metabolism of fat stores
Correct Answer: A
Rationale: Shivering increases oxygen demand.
A client at 32 weeks' gestation is experiencing preterm labor. What is the primary goal of tocolytic therapy?
- A. To prevent fetal hypoxia.
- B. To delay delivery and improve fetal lung maturity.
- C. To reduce maternal blood pressure.
- D. To increase uteroplacental blood flow.
Correct Answer: B
Rationale: Tocolytics are used to delay preterm delivery, allowing time for fetal lung maturity with corticosteroid administration.
The nurse's initial action when caring for an infant with a slightly decreased temperature is to:
- A. notify the physician immediately.
- B. place a cap on the infant's head and have the mother perform kangaroo care.
- C. tell the mother that the infant must be kept in the nursery and observed for the next 4 hours.
- D. change the formula, as this is a sign of formula intolerance.
Correct Answer: B
Rationale: Kangaroo care and covering the head help conserve heat.
A public health nurse visits the home of a young toddler. What aspect of the home environment would the nurse expect to address with the parents?
- A. The presence of power cords plugged into capped outlets
- B. Cartoons playing on a television in the child's room
- C. The family dog is present in the house during the visit
- D. The presence of pots on the stove with handles pointing toward back
Correct Answer: B
Rationale: The nurse is encouraged to ask questions regarding the amount of recreational screen time and if the child has a television or Internet-connected device in his or her bedroom. The American Academy of Pediatrics discourages any screen media before the age of 2.
A nurse is providing discharge teaching to a new parent about car seat safety. Which of the following statements by the parent indicates an understanding of the teaching?
- A. "should position my baby's car seat at a 45-degree angle in the car."
- B. "should place the car seat rear facing until my baby is 12 months old."
- C. "should place the harness snugly in a slot above my baby's shoulders."
- D. "should position the retainer clip at the top of my baby's abdomen."
Correct Answer: B
Rationale: The correct statement indicating an understanding of car seat safety is "I should place the car seat rear facing until my baby is 12 months old." This statement reflects the current recommendation by the American Academy of Pediatrics (AAP), which suggests that infants should ride in a rear-facing car seat until they are at least 2 years old or until they reach the maximum height or weight limit allowed by the car seat manufacturer. This position provides the best protection for the baby's head, neck, and spine in the event of a crash. The other statements are incorrect: