A baby is grunting in the neonatal nursery.
Which of the following actions by the nurse is appropriate?
Place a pacifier in the baby's mouth.
Check the baby's diaper.
Have the mother feed the baby.
Assess the respiratory rate.
The Correct Answer is D
Choice A rationale
Placing a pacifier in the baby's mouth is inappropriate because it does not address the underlying cause of grunting, which can be a sign of respiratory distress.
Choice B rationale
Checking the baby's diaper is not relevant to assessing the cause of grunting. Grunting is usually related to respiratory issues rather than a dirty diaper.
Choice C rationale
Having the mother feed the baby is inappropriate because grunting may indicate respiratory distress. Feeding should be deferred until the baby's respiratory status is assessed and stabilized.
Choice D rationale
Assessing the respiratory rate is appropriate because grunting in a newborn can indicate respiratory distress. The nurse should evaluate the respiratory status to determine the need for further intervention.
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Correct Answer is D
Explanation
Choice A rationale
Numbness in the toes and heel might suggest nerve involvement but is not a typical sign of deep vein thrombosis (DVT), which involves the veins, not nerves.
Choice B rationale
Pain relieved by dorsiflexion (positive Homan's sign) is not reliable for diagnosing DVT. This symptom is outdated and not considered a definitive sign.
Choice C rationale
Spider-like and purple veins suggest superficial varicose veins, not deep vein thrombosis, which affects deeper veins and presents differently.
Choice D rationale
Swelling, redness, and warmth in the calf are classic signs of DVT due to the inflammation and obstruction of deep veins. These symptoms should prompt immediate medical evaluation and intervention. .
Correct Answer is B
Explanation
Choice A rationale
Labor dystocia involves prolonged labor. Her fast delivery history suggests the opposite, indicating rapid labor progress.
Choice B rationale
Rapid labor progression, frequent contractions, and previous short labors suggest she is at risk for precipitous labor, requiring immediate preparation for delivery.
Choice C rationale
Cephalopelvic disproportion indicates size mismatch between baby and pelvis, not rapid labor. Her history of quick deliveries does not align with this condition.
Choice D rationale
False labor typically involves irregular, less intense contractions. Her regular, intense contractions and labor history suggest active labor, not false labor.