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A nurse is caring for four newborns in a special care nursery.
Which of the following newborn assessment findings requires immediate intervention?

A.

Blue coloring of the hands and feet in an 8-hour-old newborn.

B.

Small raised pearly spots on the newborn's nose.

C.

Apical heart rate of 140 bpm.

D.

Nasal flaring and grunting.

Answer and Explanation

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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View Related questions

Correct Answer is C

Explanation

Choice A rationale

A reaction from an epidural can cause side effects such as hypotension and shivering, but it is not related to tachysystole.

Choice B rationale

When the fetus's heart rate drops below baseline, it is termed bradycardia, not tachysystole. This condition can occur due to various reasons, including cord prolapse or placental insufficiency.

Choice C rationale

Tachysystole is defined as more than five contractions in 10 minutes. This condition can lead to reduced blood flow to the fetus, resulting in fetal distress.

Choice D rationale

Pitocin is a medication used to induce labor and can cause tachysystole, but the administration of Pitocin itself is not the definition of tachysystole. It's the increased frequency of contractions that defines the condition.

Correct Answer is B

Explanation

Choice A rationale

The fetal heartbeat cannot typically be heard via Doppler as early as 4 weeks of pregnancy. At this stage, the heart is still developing, and it is too soon for external detection with a Doppler device.

Choice B rationale

The fetal heartbeat is generally detectable by an external Doppler device around 10-12 weeks of pregnancy. This is the period when the heartbeat is strong enough to be picked up by the device.

Choice C rationale

Feeling the baby move, known as "quickening," typically occurs around 18-24 weeks of pregnancy, not 6 weeks. This sensation is different from hearing the heartbeat.

Choice D rationale

While the heart begins to form around week 5, it is not detectable by Doppler at 6 weeks. The technology does not have the sensitivity to detect such an early heartbeat externally.

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