A nurse is caring for four newborns in a special care nursery.
Which of the following newborn assessment findings requires immediate intervention?
Blue coloring of the hands and feet in an 8-hour-old newborn.
Small raised pearly spots on the newborn's nose.
Apical heart rate of 140 bpm.
Nasal flaring and grunting.
The Correct Answer is D
Choice A rationale
Blue coloring of the hands and feet in an 8-hour-old newborn (acrocyanosis) is a common, benign finding as the newborn’s circulatory system adjusts post-birth. It does not require immediate intervention.
Choice B rationale
Small raised pearly spots on the nose (milia) are harmless and common in newborns. They do not necessitate any intervention.
Choice C rationale
An apical heart rate of 140 bpm is within the normal range for newborns and does not require intervention.
Choice D rationale
Nasal flaring and grunting are signs of respiratory distress in a newborn. This condition demands immediate intervention to ensure the newborn’s airway is clear and breathing is adequately supported.
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Correct Answer is ["B","D","F"]
Explanation
Choice A rationale:
Supplementing with formula is not necessary based on the given information. The baby is voiding and passing stools adequately, indicating proper feeding. Instead, feeding on demand and ensuring frequent breastfeeding will help address any concerns about the baby's weight.
Choice B rationale:
Feeding 8 to 12 times per day and on demand is recommended to ensure adequate milk supply and proper growth and development of the newborn. Frequent feeding helps to establish and maintain milk production.
Choice C rationale:
Using plastic-lined breast pads is not recommended as they can trap moisture and create an environment that promotes nipple irritation and infection. It is better to use breathable, non-plastic-lined breast pads.
Choice D rationale:
It is correct that a newborn's stools should transition from the dark greenish color meconium to a yellow color within a few days as the baby begins digesting breast milk.
Choice E rationale:
Drinking more whole milk does not directly increase a mother's milk supply. Milk supply is primarily regulated by the frequency and efficiency of breastfeeding or pumping.
Choice F rationale:
Expecting the breasts to feel full, warm, and slightly tender when the milk comes in is accurate. This usually occurs around the third or fourth day postpartum and indicates that the milk production process is underway.
Correct Answer is C
Explanation
Choice A rationale
The placenta does not provide thermoregulation; that function is managed by maternal thermoregulation and the amniotic fluid which insulates the fetus.
Choice B rationale
Amniotic fluid cushions the fetus from maternal movements, not the placenta. The placenta's role is more focused on nutrient and waste exchange.
Choice C rationale
The placenta facilitates metabolic functions and gas exchange, supplying oxygen and nutrients to the fetus while removing carbon dioxide and waste products, ensuring fetal development.
Choice D rationale
The placenta doesn't provide a sterile environment. This is accomplished by the amniotic sac and amniotic fluid. The placenta connects the fetus to maternal blood supply, ensuring necessary exchanges for fetal growth.