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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 A

Explanation

Choice A rationale

Anaphylactoid syndrome of pregnancy (also known as amniotic fluid embolism) occurs when amniotic fluid, fetal cells, hair, or other debris enter the mother's bloodstream, triggering

a serious reaction. It can cause sudden shortness of breath, cardiovascular collapse, and other severe symptoms immediately after a rupture of membranes and is a rare but critical

obstetrical emergency.

Choice B rationale

Abruptio placentae involves the premature separation of the placenta from the uterine wall, which leads to bleeding and potential fetal and maternal distress. However, it does not

typically present with sudden cardiorespiratory collapse or shortness of breath immediately following membrane rupture.

Choice C rationale

Uterine rupture refers to a tear in the wall of the uterus, usually due to trauma, labor stress, or previous surgical scars. While it is a severe condition, it usually presents with

abdominal pain, vaginal bleeding, and fetal distress rather than sudden respiratory failure.

Choice D rationale

Disseminated intravascular coagulation (DIC) is a condition affecting blood clotting processes, often secondary to other conditions like severe preeclampsia, sepsis, or trauma. It

generally presents with bleeding and clotting issues but not sudden respiratory or cardiovascular collapse.

Correct Answer is ["A","B","C","D","E"]

Explanation

Choice A rationale

Postpartum blues typically resolve within the first two weeks postpartum and involve mild symptoms like mood swings and irritability. In contrast, postpartum depression can persist

longer and requires treatment.

Choice B rationale

Symptoms of postpartum blues usually disappear without medical intervention, whereas postpartum depression often needs professional treatment to manage the more severe and

persistent symptoms.

Choice C rationale

Postpartum depression can impair a mother's ability to care for herself and her baby safely, requiring intervention to prevent harm. Postpartum blues do not typically cause such severe

functional impairment.

Choice D rationale

Postpartum depression may require antidepressants for treatment due to its severity. Postpartum blues generally do not necessitate such interventions and are managed through

support and reassurance.

Choice E rationale

Postpartum depression can occur at any time within the first 12 months after delivery, while postpartum blues are usually confined to the initial two weeks postpartum.

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